Intermountain Healthcare Leaders Share Insights on Middle Rev Cycle Optimization

Leaders at Intermountain Healthcare discuss their journey merging physician and CDI teams and implementing the use of AI to streamline its middle revenue cycle.

Strong CDI and physician collaboration directly contributes to the overall health of an organization's revenue cycle. With the growth of automation, data availability, and tracking, it is increasingly important for the middle revenue cycle to become a priority for healthcare organizations.

That's why Kearstin Jorgenson, operations director of physician advisor services, and Dr. Kory Anderson, medical director of physician advisor services, CDI, and quality, at Intermountain Healthcare worked to streamline their middle revenue cycle by bringing their physician and CDI teams together and implementing AI.

For Intermountain Healthcare, revenue integrity and revenue cycle optimization are the ultimate goals and building a united team within the middle revenue cycle focused on patient experience and safety produced high-quality results that aligned with high-quality care.

Finding and addressing the gaps

According to Jorgenson and Dr. Anderson, CDI and physician communication was a large gap in their revenue cycle. They would often reach out to the physician advisor department to ask for help to reach physicians, message items appropriately, and talk with them peer-to-peer.

Intermountain Healthcare was also dealing with archaic, manual processes and a lack of buy-in. This made it difficult to ensure the true clinical picture of the patient was captured and done in a way that allowed for accurate reporting on measures like case mix index, patient safety indicators, and risk of mortality scores.

This is when Jorgenson and Dr. Anderson knew they needed a partnership.

Individually the departments were strong, but they needed to work together to really improve their revenue cycle. At Intermountain Healthcare, CDI teams are the experts in documentation, opportunities, and trends, whereas the physicians have expertise in effectively communicating peer-to-peer.

When the CDI team began talks with hospital leadership about how best to bring the two areas of expertise together, it became apparent that having a physician leader in the CDI team would be beneficial.

The physician advisor department already had champions and educators, so it made sense to position them to be the frontline advocates with the CDI nurses on CDI work.

Meanwhile, Jorgenson and Dr. Anderson said there was an executive leadership change, and multiple departments (including the CDI and physician advocacy teams) came together under one umbrella: the office of patient experience.

Through all of this, the two teams were able to align their work in more meaningful ways. After transformational change and the new operational footprint was in place, Intermountain Healthcare focused on three areas critical to the success of this new collaboration:

• Champions and advocates: Responsible for promoting the importance of the program, hosting regular meetings, and advocating for engagement in CDI workflows
• Strategy: The Intermountain Healthcare team's strategy is built on three pillars
  • Their approach to engaging providers
  • The design of their CDI integration within the provider workflow
  • Their commitment to always bridging CDI and physician work to the patient
• Data transparency: Focused on establishing key performance indicators with medical leaders, overseeing the dissemination of reports, and highlighting metric success to senior leaders

To help streamline even more, Intermountain Healthcare also turned to computer-assisted physician documentation powered by 3M AI, which provides best practice nudges to physicians during documentation, applies clinical reasoning across the patient encounter, and helps physicians get things right the first time, avoiding rework and associated administrative burden by the CDI team.

The benefits of added automation and of bringing the two teams together underneath the office of patient experience were vast, Jorgenson and Dr. Anderson said, as it puts the big picture emphasis on improving the patient experience and quality of care as opposed to solely looking through a financial lens.

With the two teams working together, it unites all the functions that contribute to the capture, management, and collection of patient service revenue.

Intermountain Healthcare says it is now able to effectively collaborate, which contributes to better coding and documentation capture, thus reducing the risk of noncompliance, optimizes payment, and minimizes the expense that comes with fixing problems later on.

"The loudest message for us is the patient," Jorgenson said. "We want to make sure we are doing the right thing for them, ensuring they receive safe, quality care and making sure we provide that care consistently."

Challenges and solutions

There were obstacles to undergoing such a large endeavor, Jorgenson and Dr. Anderson said. Getting engagement from physicians was one of the biggest challenges for the team—but there were solutions.

Once the two teams aligned, it was still tough to engage physicians, Dr. Anderson said. What made the difference was getting third-party benchmarking data on quality. Then the Intermountain Healthcare team wasn’t solely comparing themselves against other facilities or systems in the same area, but rather facilities and systems across the country.

"Seeing the data was eye-opening to our system leaders. Some of the data was very good, and other data was not so good. It led to the fact that we need to do well because this is what patients and other folks see about us as an organization and can use it to decide where they may or may not get their care," said Dr. Anderson.

Another challenge was that before the teams came together, they were dealing with manual workflows and processes that couldn’t support Intermountain Healthcare’s focus on quality and financial measures. While physicians and CDI teams are both invested in complete, accurate patient records, their workflows were often misaligned.

To make improvements and increase optimization, Intermountain Healthcare turned to AI.

When doing so, it was critical to intersect the new system with the physicians’ workflow in the EHR. The goal was to use AI to automatically nudge physicians about common document deficiencies up front. A change that would reduce rework and free the CDI team to focus on more complex quality reviews.

Following this change the results included:

• The nudges proactively support physicians in addressing common documentation gaps before the note is saved
  • Physicians can rapidly address the nudges and gaps in real-time instead of having to dig for queries later
  • The AI generates a nudge when appropriate by continually applying clinical reasoning across the patient encounter
  • It brought together traditionally siloed physician and CDI workflows, enabling both teams to take advantage of the same clinical understanding

Intermountain Healthcare also redesigned the workflow for the new team through account prioritization and relying on AI to generate prioritized worklists focused on cases with the most opportunity for improvement. Since this change, quality indicators and second-level mortality reviews have become part of the standard workflow.

Uniting individual facilities within the healthcare system was also a challenge for the organization. Large healthcare systems may be united by a vision and a direction, but each facility has its own nuances and differences, and they aren’t all staffed the same.

Intermountain Healthcare found success by partnering with facilities on an individual basis to understand how they are best suited to own and drive the work and then tailor the approach from there.

Another challenge was hesitancy, said Jorgenson. Both the CDI and the physician advocacy teams have a lot of skilled, experienced staff, but when Intermountain Healthcare first aligned the two, Dr. Anderson and Jorgenson noticed that seasoned professionals were hesitant to admit when they didn’t know something. They didn't want to be seen as someone who didn’t have a depth of understanding.

They focused on that dynamic and worked to change it. When someone did ask a question or admitted that they didn’t know something, it was met with positive reinforcement.

 "We’re stronger when we're able to rely on each other's expertise," Jorgenson said. "If you don't know something, that's fantastic. Bring it up."

Tips for other organizations

Center key performance indicators (KPI) on quality metrics

Dr. Anderson and Jorgenson have talked to numerous facilities around the country, and they see many aligning under a finance focus. Finance can be the loudest message sometimes, but what needs to resound is quality, they said.

Intermountain Healthcare focused on quality metrics that were directly impacted by clinical documentation, physician engagement, and education.

"We used to struggle to get an audience," Dr. Anderson said. "Now people are coming to us to talk about strategies and what they could do to improve those metrics."

Bring teams together in a way that still enables them to do their best work

For Intermountain Healthcare, the CDI nurses continue to focus on trends and identify what the team needs to learn. They collaborate with the physicians, and then the physicians go out and build relationships, look for common and shared understanding, and deliver educational presentations.

Bring education work in-house when possible

Intermountain Healthcare used to contract education out to vendors. Now the team does in-house training whenever possible.

Dr. Anderson and Jorgenson say they're getting better engagement with providers because educational sessions are happening between colleagues.

The person leading the session and those who attend see and work with each other in the hospital every day. This allows for more natural accountability and continuous improvements and adjustments because conversations can happen on the job and in the moment, they said.

Follow-through is also greater with in-house education. Intermountain Healthcare has set up quarterly meetings to connect on what’s going well, what isn’t going well, and how to close the gaps.

Seeing results

While it's still early in the initiative, Intermountain Healthcare has already achieved results from merging teams and implementing AI.

Intermountain Healthcare says CDI efficiency has increased similar to having hired 4.6 additional specialist RNs. The increase in efficiency has allowed the CDI team to focus on more complex quality and mortality reviews.

Intermountain Healthcare has also seen significant improvements in patient safety indicator trends and a decrease in patient safety indicators, a better case mix index, improved risk of mortality scores, and higher query response rates.

Substantial progress was also made in engaging physician groups, particularly hospitalists and intensivists, and physicians are now documenting some conditions on their own without being nudged, Dr. Anderson and Jorgenson said.

Intermountain Healthcare says all of this has helped them accurately represent the complex patients they take care of in a way they weren’t able to before.

"Moving from a financial focus to a quality focus gave us a platform for change," Jorgenson said.

What’s next

Intermountain Healthcare is working to finalize its computer-assisted physician documentation rollout to rural facilities within the system while also diversifying the provider nudges.

Quantification and optimization of evidence sheets, leveraging technology to better identify clinical cohorts for review, and continuing to think through more complex CDI opportunities are all part of Intermountain Healthcare’s future plans in optimizing its middle revenue cycle.