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● Clinical Documentation


Using technology-enhanced clinical documentation to improve ACC reporting


Utilizing the correct system can drastically increase data integrity and improve data collection and submission across the organization.


By Allison Errickson, CPC-H F


or cardiology service provid- ers, a number of forces are driving the need to provide higher quality American Col-


lege of Cardiology (ACC) data elements, including increased reporting require- ments, heightened regulatory and reim- bursement scrutiny, and the expansion of appropriate use criteria (AUC). As the need to collect and submit quality data increases, so too does the realization by many organizations that there are numerous challenges in doing


KLAS reports that 45 percent of providers consider cardiology systems to be incomplete, with the majority of respondents citing clinical reporting as the missing link.


so. Issues, such as access and integration, as well as questionable data integrity resulting from inaccurate, incomplete or inconsistent procedure documentation, have emerged as key challenges across cardiology service lines. As a result, many providers are strug- gling to comply with new regulations. Confi dence in billing procedures has also been lost, as physicians, billers and coders are often left guessing whether the data they are utilizing is accurate


14 October 2013


and complete and, as a result, whether procedures are being billed at the highest appropriate rate.


Clinical documentation improve- ment (CDI) strategies that leverage properly designed technologies are key to overcoming these challenges and improving ACC data reporting.


ACC data integrity challenges T e underlying problem with ACC data integrity is that many cardiology providers lack the resources necessary to automate data capture, analysis and reporting. Yet, even for those organiza- tions with resources available, health IT solutions have done little to help. In fact, KLAS reports that 45 percent


of providers consider cardiology systems to be incomplete, with the majority of respondents citing clinical reporting as the missing link. In addition, many fi nd that these systems lack the reporting functionality necessary to compile and validate data to their best ability. As a result, many providers continue


to rely on primarily manual processes to capture and report data points, which can be highly redundant and fraught with the potential for human error – thus impacting both quality and compli- ance. Traditional manual processes are also resource intensive, requiring up to four full-time equivalents to handle the department’s registry reporting. Interoperability issues also exist. T at


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is because, when data is siloed in mul- tiple disparate systems, the procedure- documentation and hemodynamic systems are not interfaced with the electronic medical record (EMR); the result is an incomplete patient record. Further, confl icting perspectives regard- ing what data is necessary for capture and reporting can also create tension between teammates, resulting in process inertia.


Complicating the situation is the complex nature of cardiology documen- tation, which can lead to information gaps resulting in double-digit error rates, thus hindering the accurate, comprehen- sive capture of structured and compliant data. In fact, an internal audit conducted by one hospital found error rates as high as 90 percent in its cardiac catheteriza- tion lab, while another found an average error rate of 70 percent in cardiology peripherals. T e reality is that these documenta- tion and record-keeping deficiencies ultimately result in incomplete and inconsistent data that does not advance the goals of quality initiatives or allow providers to validate data submitted to the National Cardiovascular Data Registry (NCDR).


Establishing a data integrity road map To overcome these data integrity challenges, cardiology providers must


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Allison Errickson, CPC-H, is director of coding compliance for ProVation Medical, part of Wolters Kluwer Health. For more on ProVation: www.rsleads. com/310ht-203


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