Category: Healthcare

Mastering Clinical Care Quality: Strategies and Best Practices for Optimal Patient Outcomes

Healthcare is one of the most important sectors in any country’s economy. It is responsible for the provision of healthcare services to the population, with the aim of ensuring good health and wellbeing. One of the most critical aspects of healthcare provision is clinical care quality. Clinical care quality is the level of value provided by any healthcare resource, as determined by some measurement. It is an assessment of whether something is good enough and whether it is suitable for its purpose. In this blog post will discuss the importance of clinical care quality and why it is crucial to our overall health and wellbeing.

The quality of clinical care has a direct impact on patient outcomes. Patients who receive high-quality care have better health outcomes, lower rates of complications, and a reduced risk of mortality. Quality care can also lead to a reduction in the length of hospital stays and readmission rates. On the other hand, low-quality care can result in negative health outcomes, complications, and even death.

Clinical care quality is essential because it ensures that patients receive the best possible care. This means that healthcare providers must adhere to best practices and standards of care, such as using evidence-based treatments, following proper protocols and guidelines, and maintaining a high level of professionalism. Patients deserve to receive care that is safe, effective, and of the highest quality. When healthcare providers deliver high-quality care, patients have greater trust in the healthcare system, and they are more likely to seek care when they need it.

Moreover, high-quality clinical care can also lead to cost savings. When patients receive high-quality care, they are less likely to experience complications or require readmission to the hospital. This can result in significant cost savings for both patients and healthcare systems. In addition, high-quality care can lead to better health outcomes, which can reduce the need for long-term care and costly treatments. By investing in clinical care quality, healthcare providers can reduce costs and improve patient outcomes simultaneously.

Clinical care quality is also essential for the healthcare workforce. Healthcare providers who deliver high-quality care experience greater job satisfaction and are more likely to stay in their jobs. Quality care also fosters a culture of learning and continuous improvement, which can lead to a more engaged and motivated workforce. By investing in clinical care quality, healthcare providers can create a positive work environment that attracts and retains top talent.

In conclusion, clinical care quality is essential for our overall health and wellbeing. Patients deserve to receive care that is safe, effective, and of the highest quality. Quality care leads to better health outcomes, cost savings, and a more engaged and motivated healthcare workforce. As such, investing in clinical care quality should be a top priority for healthcare providers and policymakers. By prioritizing quality care, we can ensure that patients receive the best possible care, and our healthcare systems become more efficient, effective, and sustainable.

With Saince’s comprehensive set of clinical care quality services, we will make sure you are on top of all the quality improvement measures as specified by CMS and get on the road to achieve or maintain your 5 Star status.

Patient outreach services

Mobile or in-clinic diagnostic services

Part C and Part D quality measures

Health equity measures, etc.

Contact us for more information.

Elevating Physician Efficiency and Patient Care through Expert Medical Scribe Services

Medical scribe services have become increasingly popular in recent years, as healthcare providers seek to streamline their workflows and improve the accuracy of their clinical documentation. A medical scribe is a trained professional who works with healthcare providers to document patient encounters in real-time. In this article, we’ll explore the benefits of medical scribe services and how they can improve patient care.

One of the primary benefits of medical scribe services is that they can improve the accuracy and completeness of clinical documentation. Healthcare providers often struggle to keep up with the demands of clinical documentation while also providing quality care to their patients. By working with a medical scribe, providers can focus on patient care while the scribe takes care of documenting the encounter. This can help ensure that documentation is accurate, complete, and timely.

Another benefit of medical scribe services is that they can help reduce the risk of errors and omissions in clinical documentation. Inaccurate or incomplete documentation can lead to serious consequences for patients, such as incorrect diagnoses or treatment plans. By having a medical scribe present during patient encounters, healthcare providers can be confident that all relevant information is being captured accurately.

Medical scribe services can also help improve the efficiency of healthcare delivery. Providers who work with a medical scribe can see more patients in a shorter amount of time, as the scribe takes care of documentation tasks. This can help reduce wait times for patients and improve patient satisfaction. In addition, medical scribe services can help reduce administrative burdens for healthcare providers, allowing them to focus on patient care rather than paperwork.

Medical scribe services can also help support healthcare providers in providing high-quality care. By taking care of documentation tasks, medical scribes can free up providers to focus on building rapport with their patients, listening to their concerns, and developing personalized treatment plans. This can help improve patient outcomes and satisfaction, as patients are more likely to adhere to treatment plans when they feel heard and understood by their healthcare providers.

Overall, medical scribe services offer a range of benefits to healthcare providers and patients alike. By improving the accuracy and completeness of clinical documentation, reducing the risk of errors and omissions, improving efficiency, and supporting high-quality care, medical scribes can help improve the overall quality of healthcare delivery. As healthcare continues to evolve, it’s likely that medical scribe services will become an increasingly important component of healthcare delivery, helping to support healthcare providers in providing the best possible care to their patients.

Maximizing Inpatient Reimbursement and Quality of Care with Innovative CDI Solutions: A Comprehensive Approach

Clinical Documentation Improvement (CDI) solutions and services are essential for ensuring that clinical documentation is accurate, complete, and specific. Inpatient CDI services focus on improving documentation for patients who are admitted to a hospital or other inpatient facility. In this article, we’ll explore the benefits of inpatient CDI solutions and services, and how they can improve patient care.

One of the primary benefits of inpatient CDI solutions and services is that they can help improve the accuracy and completeness of clinical documentation. This can have a significant impact on patient care, as accurate documentation can help ensure that patients receive appropriate treatment and monitoring. In addition, accurate documentation can help reduce the risk of errors and omissions, which can lead to incorrect diagnoses, treatment plans, and medication orders.

Another benefit of inpatient CDI solutions and services is that they can help improve coding and billing accuracy. Accurate coding is essential for proper reimbursement and can help ensure that healthcare providers are fairly compensated for the care they provide. By improving documentation, inpatient CDI solutions and services can help ensure that the correct codes are assigned to each patient encounter, which can reduce the risk of denials and appeals.

Inpatient CDI solutions and services can also help improve patient outcomes. By improving the quality of clinical documentation, healthcare providers can more accurately diagnose and treat patients, which can lead to better outcomes. For example, if a patient is admitted to the hospital with pneumonia, but the clinical documentation only mentions respiratory distress, the care team may not realize the severity of the patient’s condition. However, if the documentation is accurate and specific, the care team can provide appropriate treatment and monitor the patient closely to ensure they are recovering.

In addition to improving patient care and reimbursement, inpatient CDI solutions and services can also help healthcare organizations comply with regulatory requirements. For example, the Centers for Medicare & Medicaid Services (CMS) require hospitals to report quality measures, which are based on clinical documentation. Accurate and complete documentation is essential for compliance with these requirements, as well as other regulatory standards.

One key feature of inpatient CDI solutions and services is the use of technology to improve the CDI process. For example, natural language processing (NLP) can be used to analyze clinical documentation and identify areas where documentation can be improved. This can help streamline the CDI process and improve the accuracy of clinical documentation.

Inpatient CDI solutions and services can also provide education and training to healthcare providers. This can help providers understand the importance of clinical documentation and how to improve their documentation practices. By providing education and training, inpatient CDI solutions and services can help ensure that providers are equipped with the knowledge and skills they need to provide high-quality care and documentation.

Overall, inpatient CDI solutions and services offer a range of benefits to healthcare providers, patients, and healthcare organizations. By improving the accuracy and completeness of clinical documentation, improving coding and billing accuracy, improving patient outcomes, and supporting regulatory compliance, inpatient CDI solutions and services can help improve the overall quality of healthcare delivery. As healthcare continues to evolve, it’s likely that inpatient CDI solutions and services will become an increasingly important component of healthcare delivery, helping to support healthcare providers in providing the best possible care to their patients.

Enhancing Clinical Documentation through Comprehensive CDI Services: Improving Patient Care and Reimbursement Accuracy

Clinical Documentation Improvement (CDI) Services are an essential component of the healthcare industry, aimed at improving the accuracy, completeness, and specificity of clinical documentation. The goal of CDI Services is to ensure that healthcare providers have access to complete and accurate patient information, leading to better care, improved outcomes, and proper reimbursement. In this article, we will discuss the importance of CDI Services and how they can benefit healthcare organizations.

One of the primary benefits of CDI Services is improved patient care. Accurate and complete clinical documentation helps healthcare providers understand a patient’s medical history, diagnosis, and treatment plan, leading to better patient care. By improving the quality of clinical documentation, CDI Services can also help reduce the risk of medical errors, which can have significant consequences for patients. In addition, accurate documentation can help providers make more informed decisions about patient care, which can improve outcomes and reduce costs.

Another significant benefit of CDI Services is improved coding and billing accuracy. Proper coding is critical for proper reimbursement, and inaccurate coding can lead to denials and appeals, ultimately resulting in lost revenue. CDI Services can help ensure that accurate codes are assigned to each patient encounter, reducing the risk of denials and appeals and ensuring that healthcare providers are fairly compensated for the care they provide.

CDI Services can also help improve compliance with regulatory requirements. Healthcare providers are subject to numerous regulations and requirements, and accurate clinical documentation is essential for compliance. For example, healthcare organizations must comply with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) and the Centers for Medicare & Medicaid Services (CMS) requirements. CDI Services can help ensure that healthcare providers are meeting these requirements, reducing the risk of penalties and fines.

In addition to improving patient care, coding and billing accuracy, and regulatory compliance, CDI Services can also provide significant financial benefits to healthcare organizations. By improving documentation, CDI Services can help healthcare providers identify areas where they can improve revenue cycle management, reduce denials, and increase reimbursement. In addition, accurate documentation can help healthcare organizations avoid costly litigation resulting from medical errors and omissions.

One of the key features of CDI Services is the use of technology to improve the CDI process. Natural Language Processing (NLP), machine learning, and other technologies can be used to analyze clinical documentation, identify areas where documentation can be improved, and automate parts of the CDI process. These tools can help streamline the CDI process, reduce the burden on healthcare providers, and improve the accuracy of clinical documentation.

CDI Services can also provide education and training to healthcare providers. This can help providers understand the importance of clinical documentation and how to improve their documentation practices. By providing education and training, CDI Services can help ensure that providers are equipped with the knowledge and skills they need to provide high-quality care and documentation.

Overall, CDI Services are an essential component of the healthcare industry, aimed at improving the accuracy, completeness, and specificity of clinical documentation. By improving patient care, coding and billing accuracy, regulatory compliance, and financial performance, CDI Services can help healthcare organizations provide better care to their patients, while also improving their bottom line. As healthcare continues to evolve, it’s likely that CDI Services will become an increasingly important component of healthcare delivery, helping to support healthcare providers in providing the best possible care to their patients.

The goal of the Saince CDI services is to increase the quality of patient care through personalized attention and education. Our CDI team is comprised of expert consultants who possess strong clinical knowledge combined with certifications in CDI and medical coding. Our experienced CDI consultants can help you design, develop or maintain your clinical documentation improvement program while increasing hospital and physician group revenue and decreasing costs. Contact us for more information.

Is MIPS really doing what it is supposed to do? Research suggests that it is not.

How well does the Merit-based Incentive Payment Program (MIPS) of Medicare measure the caliber of medical treatment that is given? According to the findings of a recent study, not very.

The 2017 introduction of MIPS, which replaced three prior quality measurement programs, aimed to enhance patient care by financially rewarding or penalizing physicians based on their performance on particular “process” and “outcome” metrics in four key areas: cost, quality, improvement activities, and fostering interoperability.

The six metrics that participating physicians choose to report on must include one outcome indicator, such as a hospital admission for a particular disease or condition. Currently, MIPS is the biggest value-based payment program in the country.

Data from Medicare statistics and claims records for 3.4 million individuals who saw about 80,000 primary care providers in 2019 were evaluated for the study by researchers. They compared doctors’ overall MIPS scores with their scores on five process measures, including breast cancer screening, tobacco screening, and diabetic eye exams, and six outcome measures, including ED visits and hospitalizations.

The findings showed there was no consistent relationship between the measures’ performance and the final MIPS ratings. For instance, doctors with low MIPS scores scored somewhat better on the other two process measures, while having much lower average MIPS scores than physicians with high MIPS scores on three of the five process measures examined.

Low-scoring doctors performed much worse on the all-cause hospitalizations per 1,000 patients metric than they did on the other four outcome measures, although they performed significantly better on the metric of ED visits per 1,000 patients. Similar to this, 21% of physicians with high MIPS scores had outcomes that were in the poorest percentile, compared to 19% of those with low MIPS scores who performed in the top quintile for composite outcomes performance.

The findings suggest that the MIPS program’s accuracy in identifying high- versus low-performing providers is really no better than chance.

For these findings, the authors provide a number of interpretations. Among them are the challenges in making meaningful comparisons when doctors are free to select the metrics they report on, the fact that many program metrics, as other research has shown, are either invalid or of dubious validity and thus may not be linked to better outcomes, and the possibility that high scores may simply be an indicator of a program’s capacity for data collection, analysis, and reporting rather than of higher quality medical care.

They claim that the latter conclusion is supported by the discovery that participants with low MIPS scores were more likely to work in independent, small practices even though their clinical outcomes were frequently comparable to those of medical professionals in large, system-affiliated practices with high MIPS scores.

This research was released in JAMA on December 6. https://jamanetwork.com/journals/jama/article-abstract/2799153

Saince announces the launch of tele-medicine feature within its clinical documentation solution

Doc-U-Scribe clinical documentation solution now comes integrated with tele-medicine workflow. Physicians and administrators can create tele-consultation sessions with patients seamlessly from within the application. This process eliminates the need for providers to use separate solutions – one for clinical documentation and another for video session.

The COVID-19 public health crisis has accelerated the use of tele-medicine solutions among healthcare provides across the nation. However, many small hospitals and physician offices do not have access to a single solution that takes care of all their needs. Physicians are forced to use multiple solutions to complete their tele-medicine workflow. They are often finding this process frustrating and cumbersome.

Doc-U-Scribe clinical documentation solution which is used by hundreds of hospitals and physician offices across the country provides an integrated and seamless workflow for clinical documentation as well as tele-medicine.   This new HIPAA compliant tele-medicine solution can cut costs, increase efficiency, and improve physician satisfaction significantly.

Saince announced that this new feature will be available to all their existing customers immediately. Saince also announced that with their plug and play model, any new hospital or physician office can be up and running with their tele-medicine program within 48 hours.

Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018

On November 1, CMS issued the CY 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period, which includes updates to the 2018 rates and quality provisions and other policy changes. CMS adopted a number of policies that will support care delivery; reduce burdens for health care providers, especially in rural areas; lower beneficiary out of pocket drug costs for certain drugs; enhance the patient-doctor relationship; and promote flexibility in healthcare.

CMS is increasing the OPPS payment rates by 1.35 percent for 2018. The change is based on the hospital market basket increase of 2.7 percent minus both a 0.6 percentage point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law. After considering all other policy changes under the final rule, including estimated spending for pass-through payments, CMS estimates an overall impact of 1.4 percent payment increase for providers paid under the OPPS in CY 2018.

CMS updates ASC payments annually by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U). The Medicare statute specifies a Multi-Factor Productivity (MFP) adjustment to the ASC annual update. For CY 2018, the CPI-U update is 1.7 percent. The MFP adjustment is 0.5 percent, resulting in a CY 2018 MFP-adjusted CPI-U update factor of 1.2 percent. Including enrollment, case-mix, and utilization changes, total ASC payments are projected to increase approximately 3 percent in 2018.

Physician Fee Schedule Final Policy for Calendar Year 2018

On November 2, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

The overall update to payments under the PFS based on the finalized CY 2018 rates will be +0.41 percent. This update reflects the +0.50 percent update established under the Medicare Access and CHIP Reauthorization Act of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience Act of 2014. After applying these adjustments, and the budget neutrality adjustment to account for changes in Relative Value Units, all required by law, the final 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $35.89. 

EMRs Taking Away Close to One-Third of Physicians’ Work Time – AMA

The EMR Time Crunch

A common complaint among physicians across practices and specialties has been the amount of time that was previously spent attending to patients is now being occupied by clinical documentation.  These time disparities can have adverse effects on physician-patient relationships, and also limit the number of patients able to receive care from a physician or practice. Value-based purchasing models are frequently the basis for physician reimbursements, and because these models require extensive documentation to accurately report the quality and cost of care, the EMR software physicians are required to use is becoming increasingly complex and time consuming.

AMA Findings

A recent study conducted by the American Medical Association focusing specifically on the use of electronic health records in academic centers concluded that an average of 27% of the participating Ophthalmologists’ time spent on patient examinations was occupied by EMR use. On average a total of 5.8 minutes per patient and 3.7 hours was spent working in EMR on any given full day of clinic.  The study also found a negative association between the amount of time spent on EMR per patient encounter and overall clinic patient volume.

The AMA study concluded what many physicians have been expressing for years: doctors have limited time to spend with patients while they are spending more time within EMRs. Aside from the strain EMR places on physicians’ time and patient relationships, it is also creating cumbersome clerical burdens when completed incorrectly or hastily. Large swaths of copied and pasted text create bloated and messy records, and a lack of training and technical knowledge can result in incorrect coding, medical errors, and frequent interruptions in the documentation process.

Physician Dissatisfaction

The amount of physician dissatisfaction has also grown with the increased implementation of EMRs. Nearly half of all physicians report feeling unsatisfied with their work-life balance, and 57% of physicians display signs of burnout. The additional time requirements of clinical documentation are a significant factor in both of these statistics. Physicians are spending an increasing amount of time outside of regular work hours completing EMRs, and an increasingly less amount of time on actual patient care and interaction. This has led to heightened levels of stress and job dissatisfaction.

Looking Forward

While the path hasn’t always been an easy one, electronic medical records are here to stay, and they do present a plethora of benefits to clinical documentation, patient care, and bottom lines. The challenge that needs to be addressed is how to make EMRs efficient and thorough, while minimizing the amount of time physicians are required to spend on them.  Perhaps the solution for better EMR efficiency lies within a hybrid workflow — a workflow that combines the traditional model of medical transcription, where physicians dictate patient encounters and trained transcriptionists and coders review the reports for accuracy and sufficiency, combined with the advantages of using a modern day EMR is the most efficient way to ensure document quality and lessen the time burden EMRs place on physicians. When the responsibility of clinical documentation is not placed solely on the physician, doctors will be able to attend to more patients, improve patient relationships, and increase their job satisfaction.

The Prevalence and Consequences of Medical Errors in American Medicine

Part I

There are numerous records that we maintain, or are maintained on us, over the course of our lives.  Our school records track our grades and accolades. Our public records track our civic life and criminality. Our resumes document our accomplishments and abilities.  And our medical records compile the history of our overall health and wellness throughout the course of our lives. Inevitably, we are all dependent on the precision of these records to portray ourselves truthfully. Any inaccuracy could have a monumental impact on some aspect of our lives. Missing credits could keep us from graduating. A mistake in our criminal background could result in the loss of liberties. And an error in our medical records could cost us our health, perhaps even our lives.

 

Patient Perception on Healthcare Safety

We trust doctors, as we should. They’re dedicated, intelligent, and went to school a lot longer than most of us did, so we put our health and well-being in their hands and trust that they will know how to fix us and keep us healthy.  A recent study out of the University of Chicago and the Institute for Healthcare Improvement found that 90% of Americans interacted with some kind of healthcare provider in the last year, and that most people’s experiences were positive. The care was comprehensive, the physicians were attentive, and they understood how to care for themselves after their visits. (1) Over all, Americans do not feel that they run the risk of experiencing a medical error. However, this could largely be contributed to a general misunderstanding of what, exactly, constitutes one.

 

Defining “Medical Error” and Patient Experience

For most of us, the thought of “medical error” conjures images of a scalpel left inside of us after a surgery or something else gruesome, newsworthy, and incredibly unlikely to ever occur. In reality, a medical error can mean a simple miswording in diagnoses, perhaps stating an injury to a right foot instead of left, or a few switched numbers in a medical code show you diagnosed and treated with something else entirely. The same study found that, after having the term “medical error” defined to them, 21% of participants expressed that they had personally experienced a medical error, while 31% said that they had cared for someone who had experienced one.  All total, 41% of adults in the United States have either personally experienced a medical error in their own care, or were directly involved in caring for someone who had. (1)

The Consequences of Medical Errors

When it comes to medical errors, 41% is a disparaging, and frankly, frightening number, especially considering that 73% of people who reported experiencing a medical error or caring for someone who had said that the mistake had some kind of long term or permanent health detriment or financial impact. There is also a clear correlation between medial errors and harm with 36% of patients who reported personally experiencing a medical error also reporting that they had been harmed while receiving medical care. (1)

Another alarming statistic coming out of this study is that only about 1/3 of the participants who reported experiencing a medical error were made aware of the error by someone at the facility where they were treated. Around half of the participants brought their medical error to the attention of medical personnel on their own. (1) The important assumption to then take from this data, is that not only are medical errors occurring frequently, most of them are not being caught by medical personnel or facility staff. This leads then to the even larger issue of medical disparity, as medical record errors tend to impact vulnerable populations more so than populations with greater health literacy, a factor closely tied to education and income.(1)

Of the participants who reported dealing with medical errors, 59% reported that the error was centered around diagnosis, where the patient was either diagnosed incorrectly, had a delayed diagnosis, or was not diagnosed at all when they were, in fact, ill or injured. (1) The reasons for misdiagnosis are broad and varying, and misdiagnosis is the leading cause of medical malpractice suits in the United States. Diagnostic errors can have dire, long lasting, and even fatal consequences for patients, and yet they are so common that nearly everyone will experience at least one incorrect or delayed diagnosis in their lifetime. (2)

The question then becomes, what is causing such a high prevalence of medical errors and what can be done to rectify that?

Changes in Medical Documentation and Resulting Challenges

In 2004, thanks to new government incentives, medical records began to change with a push from paper charts to electronic archives. While the benefits of EMRs are undeniable—they can lower costs, enhance efficiency, and make patient records immediately available across care settings– the transition, unfortunately, has been less than smooth. Many medical facilities are still scrambling to fully and comprehensively changeover. (3)

One of the biggest hinderances to care and sources of medical errors is the extra documentation burden that now falls on doctors. Prior to EMR, physicians would fill out charts or record their observations, and those documents would then go to a trained medical transcriptionist, a coding expert, and then a billing specialist. In this new system of clinical documentation, doctors are responsible for filling out patient charts and coding, often using clunky systems that they are ill-trained to use. (3) Not only does this result in a substantial amount of physicians’ time shifting from patient interaction to documentation as they navigate unfamiliar and complicated computer programs, but it also drastically reduces the potential for any mistakes that physicians might have made to be caught and queried by professionals trained in transcription and coding. 

In addition to the obvious consequences placed on patients when medical errors arise from EMR complications, medical documentation is also a significant factor in the increasing rise of physician burnout. Physicians report higher levels of job dissatisfaction when the amount of time they spend on documentation encroaches on, and even surpasses in many cases, the amount of time they spend on patient care. (4) Essentially, new clinical documentation standards are forcing doctors to perform tasks and use technology with which they’ve had practically no training, resulting in transitional delays with the learning curve, professional frustrations, and a high prevalence of mistakes.

 

New Solutions in Traditional Practices

Medical errors are costly and dangerous and combatting them is a top priority in patient safety and hospital efficiency. With EMR hiccups contributing to a substantial amount of errors in medical documentation, the most obvious solution to begin combating medical error is to elevate the quality, capabilities, and usability of clinical documentation workflows. New software solutions and technology, specifically backend speech recognition and natural language processing, are capable of significantly improving the quality and accuracy of medical transcriptions.

The traditional transcription model where physicians dictate patient encounters and trained transcriptionists and coders review the reports to ensure quality and integrity is by far the most comprehensive way to prevent medical errors. Thanks to advancements in transcription technologies, the cost of transcription has come down significantly, and can more than offset the costs accumulated as a result of the medical errors it can eliminate. With new solutions and technologies, the outlook for not only reducing medical error, but enhancing the entire system of medical transcription and diagnosis, is exciting and promising.