MedCDI: A technology-based documentation and quality improvement initiative in neurosurgery

Abstract

Background: Clinical documentation of patient care alters coding accuracy of Medicare Severity Diagnosis-Related Groups (MS-DRGs), expected mortality, and expected length of stay (LOS) which impact quality metrics. We aimed to determine if neurosurgical quality metrics could be improved by facilitating accurate documentation and subsequently developed a mobile application and educational video to target areas of opportunity.

Methods: Vizient software was used to analyze MS-DRGs and expected LOS for sample of patients requiring surgery for spinal pathology, brain tumors, and subarachnoid hemorrhage (SAH) between January 2019 and August 2021. Chart reviews were conducted to discover variables missed by documenting provider and/or coder.

Results: Review of 114 spinal surgeries, 20 brain tumors, and 53 SAH patients revealed at least one additional variable impacting LOS in 43% of spine, 75% of brain tumor, and 92% of SAH patients, with an average of 1 (1.25), 2 (1.75), and 3 (2.89) new variables, respectively. Recalculated expected LOS increased by an average of 0.86 days for spine, 3.08 for brain tumor, and 6.46 for SAH cases.

Conclusion: Efforts to accurately document patient care can improve quality metrics such as expected LOS, mortality, and cost estimates. We determined several missing variables which impact quality metrics, showing opportunity exists in neurosurgical documentation improvement. Subsequently, we developed an educational video and mobile-supported application to specifically target these variables. To the best of our knowledge, this represents the first initiative to utilize the proven powers of mobile phones in health care toward the novel application of specifically improving neurosurgical quality metrics.

Keywords: Brain tumor; Documentation improvement; Mobile application; Quality metrics; Spine; Subarachnoid hemorrhage.

Figure 1:

Mobile application to facilitate clinical documentation. Data in this figure are an example and do not represent an exact Vizient risk model. (a) Home page where department can be selected, (b) department page where relevant procedure can be selected, and (c) procedure page showing applicable variables to document. Certain variables can be expanded for further explanation, (d) search page allows user to search for any variable in the application. Clicking the variable opens a descriptive page providing variable explanations.