(UroToday.com) The Society of Urologic Oncology (SUO) 2021 annual meeting in Orlando, FL hosted a special presentation by Dr. Kenneth G. Nepple, MD that addressed the importance of health information technology to improve clinical processes and patient care. Although Dr. Nepple is still a practicing urologic oncologist, he has assumed many administrative and leadership tasks within The University of Iowa Health Care System that have provided him with a unique perspective on how to address issues across these two disciplines.
The main objective of his talk was to emphasize practical advice on how one can impact their own institution through his own experiences, mainly with regards to the digitalization of care.
He began his talk by noting that although urologists have been keen to adopt new surgical technologies, we have not had the same mentality with regard to electronic health records (EHR). Urologists, and physicians alike, have adopted a “got-to” instead of a “get-to” mentality and phrases such as “Death by a Thousand Clicks” have been coined. Common issues/complaints have included:
- Documentation requirements
- Increased regulations
- Compliance requirements
- Billing/coding difficulties
- Joint commission policies
- Quality/safety metrics
It has been suggested that to combat physician burnout and improve patient care, we need to fix the electronic health record system. The target audience with EHR, similar to other disciplines, can be broken down into five groups: Innovators (tech enthusiasts), early adopters (visionaries), early majority (pragmatists), late majority (conservatives), laggards (skeptics).
In Dr. Nepple’s own words, the roadmap to change includes identifying an unmet need, showing its value, and asking for support. This is how he believes he has been able to turn a 0.50 full-time equivalent (FTE) into 150% productivity. This can result in service + education + research. He went on to give credit to the importance of physician leadership within the hospital.
He next shared a personal story from 2014, when there was significant displeasure with the state of Iowa Hospital’s EHR system at that time. With the assistance of one of his medical students, John Gravelle, they quantified the displeasure which was more pronounced in the staff physicians (compared to the resident urologists). Next, they detailed the specific issues (too many navigational options, inefficient use of the cancs, disconnected flow of clinical information, etc.) and presented it to their institution to make the recommended changes. A post-implementation survey distributed 4 months post-deployment demonstrated significant improvement in the overall satisfaction scores. Other personal lessons learned included the importance of not :”kimping on the screen”. There are recommended statistics for effective use. Importantly, adoption of software change is contingent on available hardware.
Dr. Nepple went on to detail the considerable financial and administrative staff support that is required for information systems teams (capital budget >$61 million at Iowa Hospital, 435 full time staff members, ~20,000 computers, 6 Petabyte storage). This team also monitors provider efficiency profile by monitoring the hours during which physicians perform work (especially after workhours) and when patients access portals to check test results.
He went on to discuss the importance of a culture of clinical documentation improvement with regards to accurate risk adjustment, quality reporting, and, significantly, accurate reimbursement. In 2013/2014, a urology pilot quality improvement project was carried out that identified suboptimal documentation of the service and inaccurate under-quantification of comorbidities. This impacted their revenue and rankings and led to frequent queries from nurses. The significance of this issue is highlighted in the radical cystectomy reimbursement procedure space, whereby accurate documentation of comorbidities can lead to a 2.95-fold increased reimbursement for the same procedure if more comorbidities are accurately documented. This, along with many other improvements, led to the Urology department in Iowa becoming a “best performer” service line.
Another area of deficiency was the documentation of malnutrition in inpatients. Five percent of patients had a diagnosis of malnutrition with poor documentation and, thus, significantly lost institutional reimbursement during their stay. Via collaborative efforts with multiple hospitals, a workflow for easier documentation was developed and has been since piloted across multiple centers across the US. Each documentation of malnutrition had a reimbursement potential of $1,877-3,652. Consequently, the percent of patients in the hospital with a malnutrition diagnosis increased from 3.6% in 2012 to 18.9% in 2021.
Another key point to consider is the importance of mobile technology and resident engagement. An example from his institution was providing the residents with iPads to assist with electronic learning. They developed an education application named iUrine (Iowa Urology Residents Innovating Education). Patient-entered questionnaires are also important to identify deficiencies, mainly done via patient administered questionnaires. In order to increase one’s efficiency of documentation in clinics and on the wards, the use of pre-populated smart phrases that contain educational material, cite the existing literature, etc. are crucial. Illustrations that help both patients and physicians are a key component that Dr. Nepple has incorporated into his documentation.
Presented by: Kenneth G. Nepple, MD, Associate Chief Medical Information Officer, Physician Value Officer, Physician Advisor for Clinical Documentation Improvement, Associate Professor of Urology, Department of Urology, University of Iowa Health Care, Iowa City, IA
Written by: Rashid Sayyid, MD, MSc – Urology Chief Resident, Augusta University/Medical College of Georgia, @rksayyid on Twitter during the 2021 Society of Urologic Oncology (SUO) Winter Annual Meeting, Orlando, FL, Wed, Dec 1 – Fri, Dec 3, 2021.