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Documentation Improvement Helps Value-Based Purchasing
By Jonathan Elion, MD, FACC

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

By way of introduction, VBP, a requirement by the Affordable Care Act, focuses on reducing health care costs while improving quality. This initiative is sometimes referred to as pay for performance, or P4P. More than 60% of all health care payments will be based on quality outcomes by the year 2018. However, this requires immediate attention by hospitals, not in 2018, because performance for certain quality measures in 2016 will shape payments two years later.

One of the major measures used for VBP is the AHRQ PSI 90 Composite, published by the Agency for Healthcare Research and Quality (AHRQ). 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 deep vein thrombosis;
• postoperative sepsis;
• postoperative wound dehiscence; and
• accidental puncture or laceration.

Coders and CDI programs can help hospitals properly document their performance against patient safety indicators (PSIs) by documenting and coding 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 physician did), the patient would be excluded from reporting if there is also a pleural effusion (fluid in the chest cavity).

While hospital executives are getting up to speed on the potential impact of VBP on their finances, coders and CDI specialists must 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, I was offered the following observation from an audience member: "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, MD, FACC, is a practicing board-certified cardiologist in Providence, Rhode Island, an associate professor of medicine at Brown University, and founder/president of ChartWise Medical Systems.