This is a heady time for health information (HI) professionals, when we can leverage new and emerging technology as well as reap the benefits of mature application solutions to solve challenges. The time is right. As an example, I presented on this topic at the AHIMA21 Virtual Conference last September, and my organization, PeaceHealth, which operates in Alaska, Oregon, and Washington, is already moving quickly to employ many of the technologies I showcased.
Although a number of technology projects were abruptly halted when the COVID-19 pandemic began, many organizations have since doubled down to quickly implement new solutions that not only have financial returns but improve the patient experience both virtually and in person. Also, as with many industries, we are reeling from workforce challenges stemming from vaccine mandates, competition for virtual resources, and pandemic-related non-productive time. Technology solutions can assist in many of our HI functional areas to shore up staffing gaps, gain efficiencies, and decrease turnaround time in key metrics, elevating many positions from clerical to knowledge worker.
Diving into an array of technology options from a variety of vendors can be overwhelming, so it is critical that we tie each potential initiative to the achievement of strategic and operational goals. This requires careful of analysis of current performance and solid predictions of future state workflow efficiencies with anticipated savings and financial returns. A solid business proposal should proceed the presentation of a technology proposal to the key stakeholder group to achieve buy-in and develop a sense of urgency around the implementation pathway.
Many of these technology solutions are dependencies for gaining deeper consumer engagement, compliance with interoperability regulations, and ultimately improvement in population health to advance value-based care models. These solutions will address the significant disruptions the healthcare ecosystem has experienced in the past five years, including shifting demographics and growth in chronic lifestyle diseases; technological advancements in healthcare; the transition to value-based reimbursement; and the projected skill shortage.
Getting a Read on Leaders’ Tech Wish Lists
A report, “Top of Mind for Top Health System 2021,” published in October 2020 by the Center for Connected Medicine and KLAS, explored health system strategies challenges, and priorities for the most impactful health technology areas. Three areas—telehealth, artificial intelligence (AI), and revenue cycle management (RCM)—were identified by health system senior leaders as front and center for both dealing with the uncertainty and instability caused by the pandemic and initiatives necessary to address virtual and other consumer-facing priorities.
Health systems are also focusing on creating and/or expanding their digital front door to enable patient estimate creation, self-scheduling, virtual visits, access to medical records, and bill payment. Also, to fuel these initiatives, many organizations are exploring and/or advancing AI to reduce costs and address workforce challenges. Many senior leaders who were focused on cash acceleration strategies are continuing to push their RCM/coding/clinical documentation integrity (CDI) teams to reimagine their workflows and reduce the cost to collect.
Many of the respondents in the report were optimistic about the future and felt that a lot of innovative work has come out of the rapid response to the pandemic, especially in the telehealth arena. There is a lot of innovative work and applications to support RCM, coding, and CDI. Advanced/predictive analytics will assist with fueling the avalanche of payer denials and downgrades received during the past two years of the pandemic. The report also highlighted revenue cycle as “the area of healthcare operations most frequently cited as needing significant innovation and disruption.”
New and Coming Soon
Some of innovative strategies that PeaceHealth has implemented or is in the process of implementing include the following:
- Natural language processing (NLP) and computer-assisted physician documentation (CAPD) is fully implemented in CDI and coding.
- Advanced coding sequencing technology to assure external reporting of quality outcomes.
- Expansion of NLP to capture the social determinants of health (SDOH) to fuel value-based care requirements.
- Advanced coding audit platforms, leveraging predictive analytics to focus on the most impactful case selection approach.
- Cloud-based advanced coding/CDI workflow capabilities utilizing advanced AI to extract clinical conditions to prioritize worklists and enable full integration and exchange of data both concurrent and retrospectively.
- Professional fee coding and charge capture is leveraging CAPD and NLP to perform single-path coding and automated coding based on documentation requirements.
- AI and deep machine learning to automatically index documents without bar code technology.
- Robotic process automation (RPA) to address release of information, denial management, authorization, access requirements, and patient financial services functions.
- Interoperability platform – payer integration using Office of the National Coordinator for Health Information Technology (ONC) interoperability and exchange protocols to reduce administrative burden and obstacles to payment, and ultimately impact value-based care outcomes.
- Expansion of portal capabilities to support the patient’s ability to receive an estimate, request a record, schedule/change an appointment, access their record and results, receive medical advice, communicate with their care team, access the virtual visit platform, complete pre-visit questionnaires, evaluate the provision of care and their provider(s), pay bills, and update their contact information.
As PeaceHealth leans into these technologies, we have undergone unprecedented workforce challenges with the ongoing pandemic, resulting in a paradigm shift in resourcing our initiatives and scaling up or down to meet these challenges. The following list details the shifts.
- Remote versus on-site: PeaceHealth has determined, with rare exception, that maintaining a remote workforce post-pandemic is working. Although coding was the only functional area that maintained a remote footprint, it was working well for CDI and health information management functional areas with the exception of a few residual paper dependent workflows (which are being addressed). Revenue cycle management functions, with the exception of patient registration and financial counseling, were also able to effectively work remotely. Tight productivity standards and tight metrics enable this strategy to be effective. The cost to collect has reached a new pinnacle of excellence.
- Outsource opportunities: PeaceHealth took another look at its outsource partners as it redefined outcomes and workflows, re-examining their need and purpose. In some cases, especially the back end of the revenue cycle, insourcing made financial sense. In other instances, a better financial arrangement could be realized in centralizing inventory as in the case of record retention. Diagnosis-related group (DRG) underpayment vendor relationships were chosen based on their technology, contingency rate, and their wrap around clinical and physician services to uncover documentation opportunities.
- Offshore options: Although many organizations look to offshore as a panacea for cost reduction and predictable turnaround times, it does not always achieve the expected outcomes. PeaceHealth outsources transcription services (small volume) and one coding and charge capture service line. Prior to the pandemic, the corporation was hit with a cyber-event and, post-pandemic, the company was plagued with the impact of its service center shut down initially, and there were workforce outages with the last two variants. Fortunately, PeaceHealth renegotiated its contract to require onshore staffing to offset outages, and the company has done a great job of communicating and pivoting to assure a quick recovery.
- Opportunity to re-train and transfer staff to new roles post technology implementation: There have been several examples where under-resourced functions were the recipient of staff whose role was no longer necessary due to the implementation of AI initiatives. Due to pandemic-related attrition, we were able to leverage our learning management platform, coupled with in-house training to move some of our HI roles to higher level identity management/data integrity analysts, and we were able to promote a few high performing coding professionals to informaticist roles and a health information management team leader to a high-level analyst role. We were also able to create a health information management educator role for our team from an analyst role. Post-CAC implementation, we were able to close the staffing gap of six outpatient positions and at least five professional fee coding positions, despite an addition of 150 providers, three new practice acquisitions, and one community connect site during the past year.
- Centralization versus decentralization of functions: Although the organizational chart paints a centralized picture, there were some functions that were geographically separated based on legacy expectations from clinical leaders. Technology and examination of workflows and distribution of work provides an excellent opportunity to eliminate unnecessary silos, external databases, and leverage features to assist with overseeing and managing these functions. Single-path coding was an excellent example of a technology coding and reimbursement NLP platform, enabling one coding professional to fulfill both sides of coding for a particular specialty or ancillary department. Also, revenue integrity edits are in the process of transitioning to the outpatient coding team to assure compliance and to gain workflow efficiencies.
Advanced Technology Success Stories
Document Imaging Auto-Imaging
Advanced Optical Character Recognition (OCR) combined with deep machine learning has resulted in an EMR indexing turnaround time of under 24 hours, with the technology vendor handling any minor tuning of the AI engine. This technology platform interoperates with the document imaging/content management system to eliminate the bar code requirement for both the patient identifiers and the document type, enabling auto-ingestion of the document to its proper location in the electronic health record (EHR), saving countless hours and eliminating legacy functions such as document prep, sorting, batch preparation, and traditional quality review.
A stack of documents can even be placed on a multifunction device if a production scanner is unavailable in any order, enabling true point-of-care scanning benefits to be realized. This eliminates the need for a large, centralized scanning operation requiring courier solutions and the dependency on health information management. The organizational benefits are massive, from labor reductions to rapid document availability. Most organizations can maintain a small staff of four to five post-implementation scanning analysts to assist with the technical setup for new sites of care, quality control, addition of new document types, updates and maintenance, and workflow optimization.
Advanced CDI and Coding Technology Approaches
Many technology advancements have occurred since the first NLP CDI worklist approach was installed in 2013. Approximately 225 hospitals have implemented NLP-driven CDI with case exclusion. The current solutions go well beyond “codeable” findings and identify clinically significant findings that warrant queries. This relies upon a potentially complex combination of clinical evidence versus well-defined guidelines of coding. They key differentiator is the identification of what the physician didn’t document. CDI technology can measure the impact of the query to determine the ROI and is in wide use.
Advanced analytics is a key differentiator in product selection. PeaceHealth has implemented the features below and is partnering with its application vendor to implement a cloud-based workflow upgrade that will enable not only the advanced features showcased above but also enable better workflow and communication integration among CDI, quality, and coding. PeaceHealth is also working on two other exciting projects below:
- A code sequencing project to recognize and assure placement of codes essential for quality reporting in the top 25 positions for secondary diagnosis reporting on the claim form to CMS without disturbing diagnosis codes necessary for severity of illness and risk of mortality.
- A SDOH project to enable NLP autosuggestion to capture codes from non-provider-based documentation (e.g., care management and nursing notes) will be live at the end of March
Even in the early stages of implementing 3M 360 Encompass Professional, PeaceHealth has doubled its facility coder productivity (101 percent increase) and increased its CMI and DRG payments (all DRG payers) by $65 million in past two years. Staffing up the CDI team to incorporate quality measures resulted in a dramatic decrease in its quality observed/expected (O/E) ratio to improve its comparative quality measures.
Professional Fee Coding and Integrating with Facility Coding
Today, many professional fee coding professionals are still stuck between manual and repetitive processes, causing healthcare organizations to waste time and resources on obsolete systems and workflows. Coding professionals nowadays need reliable tools and trusted technology that can help increase productivity and efficiency.
PeaceHealth saw the opportunity to expand its coding and CDI platform to not only support essential professional fee coding and charge capture workflows (major EHR vendor for professional billing focus on provider charge capture) but to also provide advanced tools to support risk adjustment requirements and unify traditionally siloed workflow. The application incorporates edits in the coder review workflow, resulting in a clean claim rate and fewer touches by coding professionals.
By breaking down the coding silos and leveraging the benefits of an integrated coding platform, hospitals and healthcare systems can improve their coding productivity, accuracy, and compliance.
Following the implementation of the application’s feature enabling one coding professional to satisfy the requirement for professional fee and facility coding, single-path coding professional productivity increased by 55 percent in one month and reduced their average turnaround time by 2.8 days. PeaceHealth saw increases in relative value units (RVUs) most significantly in its family medicine and internal medicine departments where it more than doubled its RVUs in the first six months. After going live with the professional fee application, PeaceHealth met its goals for cleaner claim rates and a more efficient coding process.
The professional fee application provides a proprietary NLP platform to bring forward auto-suggested CPT and ICD codes to the professional services coding professional workflow, resulting in sophisticated query capabilities, smart alerts, up-to-date clinical and regulatory edits, and expert process and advisory services delivering a powerful professional fee coding workflow.
Auto-suggested coding shows the evidence of why an account should be coded in an accurate, compliant manner, which is greatly appreciated by our coding professionals who need to gain confidence in the advanced technology.
PeaceHealth is beginning it implementation journey with its EHR vendors’ embrace of the ONC interoperability exchange use cases to develop Payer Platform, which is a software solution and interoperability network that allows easier, more robust communication between payers and providers to reduce administrative burden and improve quality of care.
Patient data-sharing needs with payers have gone beyond the information conveyed in claims and other established standards. The Payer Platform will go beyond those standards and connect payers and providers through a trusted network to save time and effort and better inform care decisions.
The implementation of Epic’s Payer Platform would reduce PeaceHealth’s administrative burden throughout the revenue cycle, support care management needs and requirements, along with aligning with value-based care and promoting our Clinically Integrated Network (CIN).
The goal is to design and implement Epic’s Payer Platform with mature payers first, while soliciting participation with our other major payers.
Robotic Process Automation
Robotic process automation (RPA) refers to software that can easily be programmed to do basic tasks across applications just as human workers do. It operates at the user interface level and can be applied without any impact to existing systems.
RPA can be coupled with AI. To differentiate it from AI, think of RPA as a train used for rule-based tasks using structured data; AI is a plane that handles more complicated tasks dealing with unstructured data.
PeaceHealth has been reviewing RPA possibilities following its success with NLP, advanced OCR, and rules-based automation with real-time eligibility and authorization. An assessment was performed in 2020 to prepare a roadmap and a business plan. The project kicked off in late 2021 with the selection of a vendor to support the use cases selected to handle. A financial impact analysis was performed on the following use cases, which will be the focus of the RPA development following vendor selection. An implementation roadmap was then created to guide and govern the work.
Future Plans in 2022
Continuing and future plans for the revenue cycle, coding, and CDI for 2022 include:
The implementation of a direct-to-bill AI/NLP solution that will enable physician office and ambulatory professional fee visits to bypass coding if the documentation meets coding, medical necessity, and captures hierarchical condition category opportunities. The system will also enable selection of providers regarding audit or focused review and routing to coding worklists. This exception-based, direct-to-bill model will provide a high accuracy rate and lessen the burden for our professional fee coders.
Our team will explore the blockchain and any potential use cases for the division as we implement AI and robotics use cases. Full implementation of Payer Platform is on the docket for implementation as well as the full replacement of our content management and document management system. 2022 will be a very busy year for our teams, as we focus on our technology roadmap and implement solutions that will benefit all facets of not only the revenue cycle, coding, health information management, and CDI but will have a multitude of benefits for the entire organization.
Don’t hesitate in pitching the strategies outlined above to re-invent or refresh your legacy functions that can be restructured or eliminated with your staff oversight and direction. Focus on driving new technology rather than being a passenger in someone else’s technology bus, to lead your team to a brand-new world with meaningful roles to address what automation cannot.
- The Peterson Center on Healthcare-KFF Health System Tracker
- Neil Batra, David Betts, Steve Davis, “Forces of change: The future of health,” Deloitte Insights. April 30, 2019. https://www2.deloitte.com/us/en/insights/industry/health-care/forces-of-change-health-care.html
- David Betts, Leslie Korenda, and Shane Giuliani, “Are consumers already living in the future of health? Key trends in agency, virtual health, remote monitoring, and data-sharing,” Deloitte Insights, August 13, 2020. https://www2.deloitte.com/us/en/insights/industry/health-care/consumer-health-trends.html
- American College of Healthcare Executives’ (ACHE) Annual Survey
- American Medical Association, 2013 National Health Insurer Report Card, Administrative Burden Index, http://goo.gl/v0bse0
- Sasha Preble and Keith Shah. “Health care beyond crisis: Eight forces that will define the future.” Optum Advisory Services. 2020. https://global-uploads.webflow.com/5a6e91077bd20a0001852e86/5f58011582dd7fccd25416d9_Optum.pdf
Cassi Birnbaum (CBirnbaum@peacehealth.org) is a senior enterprise director of health information management, coding, and clinical documentation integrity at PeaceHealth Values.
Learn more about topics discussed in this article in the Evolving Healthcare Webinar series, which includes “Artificial Intelligence in Healthcare” and “The Impact of Telehealth.”