The Impact of Implementation of a Clinically Integrated Problem-Based Neonatal Electronic Health Record on Documentation Metrics, Provider Satisfaction, and Hospital Reimbursement: A Quality Improvement Project

Abstract

Background: A goal of effective electronic health record provider documentation platforms is to provide an efficient, concise, and comprehensive notation system that will effectively reflect the clinical course, including the diagnoses, treatments, and interventions.

Objective: The aim is to fully redesign and standardize the provider documentation process, seeking improvement in documentation based on ongoing All Patient Refined Diagnosis Related Group-based coding records, while maintaining noninferiority comparing provider satisfaction to our existing documentation process. We estimated the fiscal impact of improved documentation based on changes in expected hospital payments.

Methods: Employing a multidisciplinary collaborative approach, we created an integrated clinical platform that captures data entry from the obstetrical suite, delivery room, neonatal intensive care unit (NICU) nursing and respiratory therapy staff. It provided the sole source for hospital provider documentation in the form of a history and physical exam, daily progress notes, and discharge summary. Health maintenance information, follow-up appointments, and running contemporaneous updated hospital course information have selected shared entry and common viewing by the NICU team. The interventions were to (1) improve provider awareness of appropriate documentation through a provider education handout and follow-up group discussion and (2) fully redesign and standardize the provider documentation process building from the native Epic-based software. The measures were (1) hospital coding department review of all NICU admissions and 3M All Patient Refined Diagnosis Related Group-based calculations of severity of illness, risk of mortality, and case mix index scores; (2) balancing measure: provider time utilization case study and survey; and (3) average expected hospital payment based on acuity-based clinical logic algorithm and payer mix.

Results: We compared preintervention (October 2015-October 2016) to postintervention (November 2016-May 2017) time periods and saw: (1) significant improvement in All Patient Refined Diagnosis Related Group-derived severity of illness, risk of mortality, and case mix index (monthly average severity of illness scores increased by 11.1%, P=.008; monthly average risk of mortality scores increased by 13.5%, P=.007; and monthly average case mix index scores increased by 7.7%, P=.009); (2) time study showed increased time to complete history and physical and progress notes and decreased time to complete discharge summary (history and physical exam: time allocation increased by 47%, P=.05; progress note: time allocation increased by 91%, P<.001; discharge summary: time allocation decreased by 41%, P=.03); (3) survey of all providers: overall there was positive provider perception of the new documentation process based on a survey of the provider group; (4) significantly increased hospital average expected payments: comparing the preintervention and postintervention study periods, there was a US $14,020 per month per patient increase in average expected payment for hospital charges (P<.001). There was no difference in payer mix during this time period.

Conclusions: A problem-based NICU documentation electronic health record more effectively improves documentation without dissatisfaction by the participating providers and improves hospital estimations of All Patient Refined Diagnosis Related Group-based revenue.

Keywords: APR-DRG; CMI; Epic; NICU; ROM; SOI; electronic health record; informatics; neonatal intensive care unit; physician documentation.

Figure 1

Development overview of components of history and physical (H&P), progress note, and discharge summary navigators.

Figure 2

Severity of illness by pre-post neonatal electronic health record (EHR) implementation.

Figure 3

Risk of mortality by pre-post neonatal electronic health record (EHR) implementation.

Figure 4

Case mix index by pre-post neonatal electronic health record (EHR) implementation.

Figure 5

Time to complete history and physical (H&P) notes, levels 2 and 3 progress notes, and discharge summaries preintervention (dictation) and postintervention (electronic health record).

Figure 6

Trended average expected payment.