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Better notes mean better outcomes, payments — but how can organizations help physicians improve their documentation?

In a value-based world where physicians' performances are continuously measured and compared by payers, accurate and detailed documentation is essential. However, navigating ICD-10 isn't always easy, especially when few physicians are trained to memorize the specific codes and most feel their time is better spent administering patient care.

Health IT companies, like Nuance Communications, are  making documentation less burdensome and tedious for physicians through clinical documentation solutions.

In a Feb. 14 webinar sponsored by Nuance Communications and hosted by Becker's Hospital Review, Karen Landin, director of healthcare solutions marketing at Nuance, shared the details of its partnership with Vincari, a surgical documentation solution provider. Vincari Founder and CMO Lucian Newman III, MD, elaborated on the product's features and demonstrated its capabilities, while Mercedes Dullum, MD, a regional medical director at Nuance, shared insights on how clients use the product to improve documentation quality and streamline documentation practices for surgeons.

Note quality matters for risk scores

Payers rank and rate surgeons on their risk-adjusted operative mortality results, which take into account expected versus observed mortality rates. Specifically, risk-adjusted mortality rates are determined using quality data documented in the patient record that reflect patient acuity, or the severity of the patient's medical condition, and the level of medical care administered. Poor documentation or incorrect or insufficient coding could negatively affect physicians' ratings, causing health plans to incorrectly rank surgeons when compared with their peers.

Since services at ASCs often are reimbursed at lower rates than those at an in-patient setting, ASCs need to do a better job convincing payers they, too, take care of sick people in order to compete for insurer dollars, says Dr. Newman. This requires the most complete documentation to provide the most accurate reimbursement.

As healthcare providers ramp up EHR adoption and clinical documentation improvement programs — especially in the ASC space, which has historically been slower to adopt new technologies — physicians are facing more digital documentation burdens. Not only are outpatient physicians less likely, when compared to their in-patient peers, to be trained on dictation tools — which could ease some of their data-entry duties — they just want to focus on their primary reason for practicing medicine: surgery.

"It seems to us that many of the tools that are available were not created with us, the end user, in mind," Dr. Newman says.

Multiple choice style can make documentation simpler for physicians

Vincari created a tool that streamlines the documentation process. With Vincari Surgical Computer-Assisted Physician Documentation, physicians don't have to memorize ICD-10 codes — they simply need to know the rules of the coding. When searching in the Vincari Surgical CAPD tool, physicians only have to input keywords about the work they are doing or the patient's medical condition to queue a list of possible entries.

The same medical procedure may not be documented in exactly the same way for two different patients. For example, a knee-replacement procedure may have multiple codes that vary slightly based on the nuances of each patient's care. However, physicians may not be aware of these intricacies, which can lead to instances of under coding when a patient's medical condition is actually more severe than the physician's documentation reflects. Vincari Surgical CAPD drills down to the core of each query and offers multiple choice-style options to help surgeons document more complete, accurate notes that result in proper reimbursement, improved reputation and referral management.

"The reality is, in the future, more patients will be shopping for doctors based on real data," Dr. Newman says. Having clean, concise documentation ensures physicians' quality of care is accurately reflected in CMS' Merit-based Incentive Payment System or other incentive-based programs that use data and rankings.

Vincari Surgical CAPD learns with you

The tool is embedded with artificial intelligence that changes the way patient data is captured, leveraged and delivered to continually improve itself. In other words, Vincari Surgical CAPD learns its users' actions over time to improve efficiency.

Its structured, procedural documentation contrasts free-form diction-type documentations traditional throughout the industry. The structured approach offers a number of advantages — such as uniformed format and standardized language that ensures all required information is included — but also ensures physicians include the level of detail necessary to paint a more complete picture of each patient. After the user selects from an array of options under pre-set topics, Vincari Surgical CAPD auto-populates the procedure note with those additional details. It then highlights all findings unique to the patient within the documentation and alerts its users when certain required information has been left out.

Vincari Surgical CAPD employs an easy-to-use interface and is also equipped with voice recognition, image capture and e-sign capabilities so surgeons can add photos into patient notes and comply with other standards. These features help reduce complete operative report documentation time to nearly 90 to 120 seconds. The system is also able to produce a charge-capture report that can be sent to the billing and reimbursement office within the organization to begin billing process in just two hours.

Better notes mean better reimbursement and happier surgeons and administrators

About 55 specialties are using Vincari across 25 states. Of those that have tested Vincari Surigcal CAPD, 86 percent have elected to adopt the tool. "Once we find that a number of the surgeons that we start to implement with use it, enjoy it and start to realize value immediately, word spreads pretty quickly and often there's a line at the door trying to implement it as quickly as possible," Ms. Landin says, adding implementation time is roughly four to six weeks.

Once implemented, Vincari Surgical CAPD notes a 92 percent reduction in retrospective queries from clinical documentation improvement or coding specialists that result from coding confusion, leading to more accurate reports, more timely reimbursement and ultimately, better physician quality scores.

"We have not focused so much on our [notes] quality; we haven't been so concerned about it; it's just not what surgeons do. … It's not our job to know how the quality is measured. … We don't realize we need to document in so much detail," Dr. Dullum says. "By this being so easy and comprehensive, it will capture all the comorbidities necessary, all the necessary details of the operation."

With Vincari Surgical CAPD, Dr. Dullum adds, physicians see both eased workloads and improved risk scores.

For more information on Vincari Surgical CAPD, click here

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