Hospital Impact: Improve documentation to ease transition to value-based care

Nurse with a clipboard
Value-based purchasing is set out as a requirement by the Affordable Care Act, and focuses on reducing healthcare costs while improving quality. More than 60 percent of all healthcare payments will be based on quality outcomes by the year 2018. But this requires immediate attention from hospitals, as performance for certain quality measures in 2016 will shape payments for 2018.

I don’t believe that it has ever been acceptable to simply look at case mix index (CMI) alone as a measure of the impact of a clinical documentation improvement (CDI) program. Given the current activities surrounding value-based purchasing, an even greater imperative exists for healthcare organizations to implement a robust, well-rounded CDI program, and comprehensive statistics to guide it.

One of the major measures being used for value-based purchasing is known as the “AHRQ PSI 90 Composite,” published by the Agency for Healthcare Research and Quality. It is a weighted average of the adjusted observed-to-expected ratios for the following conditions:

  • Pressure ulcer
  • Iatrogenic pneumothorax
  • Central venous catheter-related bloodstream infections
  • Postoperative hip fracture
  • Perioperative pulmonary embolism or DVT
  • Postoperative sepsis
  • Postoperative wound dehiscence
  • Accidental puncture or laceration

One of the major ways coders and CDI programs can help a hospital properly document its performance against these patient safety indicators (PSIs) is to document and code conditions that may exclude a patient from being included in the calculations. For example, when evaluating a patient with an “iatrogenic pneumothorax” (air in the chest cavity caused by something a doctor did), the patient would be excluded from reporting if he or she also had a pleural effusion (fluid in the chest cavity).

While hospital executives get up to speed on the potential impact of value-based purchasing on their finances, CDI programs must also become familiar with the components of AHRQ PSI 90, and improve the documentation and coding of patients who need to be included and excluded from reporting.

At the end of a recent talk I gave on the subject, an audience member said, “The only thing that our CFO measures now is CMI. All of our CDI metrics are no longer looked at or tracked.” After considering this question carefully, I replied, “I think your CFO is about to have a rude awakening. It sounds like someone needs to provide some education to the hospital executives on value-based purchasing.”

Jonathan Elion, M.D., FACC, is a practicing board-certified cardiologist in Providence, Rhode Island, and an associate professor of medicine at Brown University.