Developing World Class Health Information –What Are the Factors That Lead To

Improvement in Patient Care, Healthcare Quality and Outcomes? The Role of Electronic Health Records, Teamwork and Coordination

of Care

Dr Nigel Umar BeejayMB BChir, MA (Cantab), FACP, CPE, Dip (Med Hyp)

Cert (Biomedical Informatics)Advanced Center for Daycare Surgery

Harley Street London

Learning Objectives

Compare and Contrast health data and information

List Factors that lead to improvement in patient care healthcare quality and outcomes

Outline the role of EHRs in improving documentation

Describe the key elements of teamwork and coordination of care

How Does Physician Documentation Impact Coding

Improvement?

Who are the Physicians?

Who are the Physicians?

• Physician are very smart people

• Do not think that you can pull the wool over their eyes

• They are committed to a vocation that puts the patient first

• They need to see logic before they change

• They tend not to be team players by design

What is the Physician Perspective?

What is the Physician Perspective?

• Change has come hard and fast and from outside

• They are scared

• Lots of new terminology

• Lots of new concepts (E&M, IR-DRG, P4P, ICD9 and ICD 10

• In SEHA hospitals roll of enterprise wide EHRs

• Rapidly changing teams

• Challenging learning

• Resistance to change

Where do Physicians Practice?

UAE Healthcare

• MENA region is fastest growing region in health care spend

• Health care model mix of US/Canadian and European models

• Hospital teams (Health Information Staff and Clinical Staff) heterogeneous

• Governmental adoption of the US system

Physicians are overloaded with information

They are scared to learn a

second language

What language do physicians speak now?

Physicians speak best to other Physicians

They are not good at teamwork

They are not great at communicating

to other members of the team

Physicians do not have a clear understanding of the process?

What do Physicians need to learn ?

What do Physicians need to learn ?

• Teamwork

• Communication

• Other Health care teams members perspectives

• Outcome on patients

• Outcome for themselves (P4P)

• Outcome for any organization

What do Physicians need to learn ?

Complete Documentation

Correct Medical Coding

Appropriate Reimbursement

WYSIWYG

What you see is what you get

Documentation Guidelines

If you can’t read it, it wasn’t done

If you can’t find it, it wasn’t done

If it is not filed in the record, it wasn’t done

If it was not ordered, it wasn’t necessary

If it wasn’t written, it wasn’t done

The Game

Documentation

Coding Level

Documentation Coding Level

Where do we want all want to be?

Future State

Where do we want all want to be?

• We want to amalgamate and learn from the histories of more developed health care systems

• We want to adhere to best practice

• We want the safest and highest quality health system on the world that is affordable to all ( payers/payors/regulators)

• We want sustainability

Evaluation and Management

Each Code

History Exam Medical Decision Making

HPI ROS PFSH

No of systems examined

DiagnosisData

Risk

Type of care

Setting

Provider

HX HPI ROS PFSH

PF Brief None None

EPF Brief 1 None

DET Ext 2-9 1/3

COMP Ext 10 3/3

Ex Bullets

PF 1-5

EPF 6-11

DET 12

COMP 18

MDM DX Data Risk

SF 1 1 Min

Low 2 2 Low

Mod 3 3 Mod

High 4 4 HIgh

E & M broken down

Each Code

History Exam Medical Decision Making

HPI ROS PFSHNo of systems examined

Diagnosis Data Risk

Type of care

Setting

Provider

New/EstablishedWork upStable/worsening

Extent of review/OrderTests/Rad/Records

4 levels

MDM Levels and Components

4 levels Complexity

• Straightforward

• Low

• Moderate

• High

3 Components

• Diagnosis/Problems

• Data reviewed

• Risk

3 Components of MDM

Number of Diagnosis and Management

Options

• Self-limited or minor

• Established problem, stable or improved

• Established problem, worsening

• New problem, no additional workup

• New problem, additional workup planned

Extent of Patient Data

• Review and/or order clinical lab tests 1

• Review and/or order radiology tests 1

• Review and/or order medicine tests 1

• Discuss diagnostic test results with performing physician 1

• Independent review of an image, tracing or specimen 2

• Decision to obtain old records 1

• Review and summarize old records 2

What is the risk of morbidity/mortality?

• Refers to patient’s level of risk at the visit

• Sources of risk

• Presenting problem

• Diagnostic procedures ordered

• Management options selected

Summate to give one of 4 MDM levels(Straightforward, low, mod, high)

Quantifying the MDM

Number of Diagnosis

Minimal

Limited

Multiple

Extensive

Data reviewed

Minimal

Limited

Moderate

Extensive

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Quantifying the MDM using points

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Diagnosis/Problem Points

Problems/Dif diagnosis No of Points

Self Limited/Minor (max 2) 1

Established Problem (Stable) 1

Established Problem (Worsening) 2

New Problem – no additional work up planned

3

New Problem – additional work up planned

4

Data Reviewed Points

Problems/Dif diagnosis No of Points

Review/Order Clinical Labs/Tests 1

Review/Order X Rays 1

Review/Order tests in medicine section (Echo/EKG/PFTs)

1

Discussion of tests with performing MD 1

Independent review of image, tracing or specimen

2

Decision to obtain old records 1

Review and summation of old records 2

Quantifying the MDM using points

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Level of Risk Levels

Minimal/Low/Moderate/High

Presenting Problems

Diagnostic procedures

Management Options

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected

Minimal * One self–limited or minor problem, e.g. cold, insect bite

*Lab tests requiring venipuncture*CXRs*ECG/EEG, U/A, echo

* Rest* Gargles* Elastic bandages* Superficial dressings

Low • 2 or more self–limited or minor problems• 1 stable chronic illnessAcute uncomplicated illness or injury, e.g. cystitis, sprain

* Physiologic tests not under stress, e.g. PFTs* Non–CV imaging with contrast, e.g. barium enema* Superficial needle biopsy* Clinical lab test requiring arterial puncture* Skin biopsies

* OTC drugs* Minor surgery w/ no identified risk factors* PT, OT• IV fluids w/out additives

Moderate

* 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment* 2 or more stable chronic illnesses* Undiagnosed new problem with uncertain prognosis, e.g., lump in breast* Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis* Acute complicated injury, e.g. head injury with brief LOC

* Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test* Diagnostic endoscopies with no identified risk factors* Deep needle or incisional biopsy* CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath* Obtain fluid from body cavity

* Minor surgery with identified risk factors* Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors* Prescription drugs* Therapeutic nuclear medicine* Closed tx of fr* IV fluids w/ additivesacture or dislocation without manipulation

High * 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment* Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI* An abrupt change in neurological status, e.g. seizure

* CV imaging studies with contrast with identified risk factors* Cardiac EP test* Diagnostic endoscopies with identified risk factors* Discography

*Elective major surgery w/ identified risk factors* Emergency major surgery* Parenteral controlled substances* Drug therapy requiring intensive monitoring for toxicity* Decision not to resuscitate or to de–escalate care because of poor prognosis

Medical Decision Making Table of Risk : use highest level documented

MDM Levels and Components

Complexity

•Straightforward

•Low

•Moderate

•High

3 Components

•Problems

•Data reviewed

•Risk

Putting all components together

Quantifying the MDM

Number of Diagnosis

Minimal

Limited

Multiple

Extensive

Data reviewed

Minimal

Limited

Moderate

Extensive

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Example: Straightforward MDM

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Straightforward MDM

CC: Common ColdAssessment/Plan: Recommend Fluids and rest

Low Complexity MDM

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Low Complexity MDMCC: Arthritis painAssessment/Plan: Pt with osteoarthritis no longer controlled by

paracetamol. Recommend OTC NSAID

Problems/Difdiagnosis

No of Points

Self Limited/Minor (max 2)

1

Established Problem(Stable)

1

Established Problem(Worsening)

2

New Problem – no additional work up

planned

3

New Problem –additional work up

planned

4

Moderate Complexity MDM

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

Moderate Complexity MDMCC: Uncontrolled dyslipidemiaAssessment/Plan: Pt with stable HTN but uncontrolled dyslipidemia not controlled

on current meds. You increase simvastatin from 20mg od to 40 mg od

Problems/Difdiagnosis

No of Points

Self Limited/Minor (max 2)

1

Established Problem(Stable)

1

Established Problem(Worsening)

2

New Problem – no additional work up

planned

3

New Problem –additional work up

planned

4

Level of MDM represents optimal laborRisk= 2 stable chronic or prescription drug RxProblem points: 3 stable or 1 stable,1 suboptimal

High Complexity MDM

Number of Diagnosis/ Problems (Points)

1

2

3

4

Data reviewed (Points)

1

2

3

4

Level of Risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

Low

Moderate

High

“Only need 2 out of three to reach level”

High Complexity MDMCC: Uncontrolled CHFAssessment/Plan: Pt with CAD and DM presents with CHF exacerbation requiring IV

diuretics

Problems/Difdiagnosis

No of Points

Self Limited/Minor (max 2)

1

Established Problem(Stable)

1

Established Problem(Worsening)

2

New Problem – no additional work up

planned

3

New Problem –additional work up

planned

4

Acuity of Care is highRisk= severe acute or chronic illnessData points: add up quickly

Evaluation and Management

Each Code

History Exam Medical Decision Making

HPI ROS PFSH

No of systems examined

DiagnosisData

Risk

Type of care

Setting

Provider

HX HPI ROS PFSH

PF Brief None None

EPF Brief 1 None

DET Ext 2-9 1/3

COMP Ext 10 3/3

Ex Bullets

PF 1-5

EPF 6-11

DET 12

COMP 18

MDM DX Data Risk

SF 1 1 Min

Low 2 2 Low

Mod 3 3 Mod

High 4 4 HIgh

MDM drives the level of care and hence the code

ER Case 1

Case 1

• 25yr old male. Pedestrian hit by car. Pt brought by EMS Unconscious. No additional history available. No past medical history or Social history available.

• Vital signs 120/80, Heart Rate 80, RR 16, Temp 37, Pulse Ox 97%.Contusion on parietal scalp. Eyes, Ears face normal. Neck immobilize with C-collar. Chest, CVS, abdomen, pelvis, -inspected, palpated , auscultated - no findings. Back examined-Normal. CNS- GCS Eyes 2, Verbal 3 , Motor 5 = 11

• Management. Oxygen, IV’s x 2 . Chest XR + ECG normal. Trauma CT - only finding is cerebral contusion. Neurosurgery is consulted for admission. Diagnosis –Cerebral Contusion

Code History PE MDM

99282 CC/HPI 1-3/No PFSH/1 ROS >6 Problems Limited/Data limited/Risk Low

99283 CC/HPI 1-3/1 PFSH/1 ROS >6 Problems Multiple/Data mod/ Risk Mod (3+3 + mod)

99284 CC/HPI >4/1 PFSH/2-9 ROS 2 by 6 Problems Multiple /Data mod / Risk Mod (i.e3+3 + mod)

UnconsciousHit by carNo ROS documented

Altered mental statusSudden, severe, hit by car“Unable to get ROS”“Unable to get PFSH”

Altered mental statusSudden, severe, hit by car“Unable to get ROS”“Unable to get PFSH”

VSSContusionHEENTChest, CVS, Abdomen,Pelvis, BackCNS GCS done

VSS 1Pupils 1Ears/Nose 1Neck 1Lungs auscultated 1Heart auscultated 1No mass/tender/L/S 2Inspection/ROM/Stabilityspine ribs and pelvis 1

Vital signsWell developed medium statureRS: dull percussion, CTACVS HS NAD/pedal pulses NADGI: No mass/tender/L/SLN: No neck/submental LNEyes: Lids/Conjunctivae NAD/PERLA

Neck: Normal/Thyroid NormalENT: Ears/Nose/Otoscopy NM/S: Spine ribs and pelvis NM/S: Digits/Nail No clubbingM/S: Head and Neck

Cerebral ContusionCXR and EKGConsult

New problem, needs Ix (4)Ordered Labs/CXR/EKG/CT (4)An abrupt Change in neurostatus – High Risk = HIGH risk MDM

New problem, needs Ix (4)Ordered Labs/CXR/EKG/CT (4)An abrupt Change in neuro status –High Risk = HIGH risk MDMTo go to highest billing 99285 2 in 9 systems

Code 99281

Not enough exam documentation or ROS

Code 99283

Hx: OKExam: low levelMDM: High

Code 99284

Hx: unchangedExam: 2 by 6MDM: High

References

• Towers, Adele L. "Clinical Documentation Improvement—A Physician Perspective: Insider Tips for getting Physician Participation in CDI Programs" Journal of AHIMA 84, no.7 (July 2013): 34-41.

• El-Kareh R, Hasan O, Schiff G. Use of health information technology to reduce diagnostic error. BMJ Quality and Safety. 2013. 22ii: p. 40-44

• http://www.mghlcs.org/projects/dxplain• https://www.visualdx.com/• Clinical Documentation Improvement: Principles and

Practice By Pamela Hess MA, RHIA, CDIP, CCS, CPC• Health Information Management Technology: An Applied

Approach / Edition 4 Nanette B. Sayles