Introduction to WakeMed Health & Hospitals
WakeMed Health & Hospitals, a health system based in Raleigh, North Carolina, faced a significant challenge regarding its electronic health record. The health system needed to improve the accuracy of documentation, but this required asking physicians to spend more time in the EHR, which was already a major source of frustration and burnout.
The Challenge
Research shows that clinicians may need as much as two hours in electronic data entry beyond the exam room for every hour of direct patient contact. Physicians with insufficient time for documentation are 2.8 times more likely to report symptoms of burnout. This created a difficult situation for WakeMed, as it needed better documentation for financial and quality outcomes, but pushing harder in the EHR risked worsening physician wellbeing and job satisfaction.
Physician Burnout
"I heard from many of our clinicians, ‘This isn’t what I trained for – I trained to care for patients, not to code charts,’" said Dr. David Kirk, chief clinical integration officer at WakeMed. "But the reality is, if we don’t document correctly, we miss out on the revenue we’re owed and the quality scores we need. It’s all connected." Unfortunately, these tasks aren’t where most physicians or advanced practice providers thrive, especially coming out of COVID, when many are already exhausted.
Proposal
To solve the documentation accuracy challenges, WakeMed used a three-pronged approach that included data, people, and technology components. The health system installed an AI-powered clinical insights platform from vendor Regard and trained those physicians on its use. "We provided a small amount of protected time to a hospitalist leader to help educate the group on the importance of the overall project and in our specific opportunities around clinical conditions," Kirk explained.
AI-Powered Clinical Insights
The Regard application helps providers by suggesting diagnoses and related supporting evidence after reviewing 100% of a patient’s electronic record. "The application’s at-the-elbow support was key in initial adoption and satisfaction," Kirk added. The AI-powered clinical insights technology integrates with the EHR and works by reviewing and analyzing a chart to surface relevant clinical insight, summarize the patient’s record, and enhance diagnoses with supporting evidence.
Meeting the Challenge
By integrating the AI platform with the EHR and streamlining the charting process, WakeMed has been able to improve documentation accuracy and enhance coding and revenue capture – helping to address both operational and burnout-related challenges. For example, a physician might diagnose a patient with sepsis and begin treatment. The AI application takes it further by pulling in multiple layers of clinical evidence to support that diagnosis, detailing the severity and contributing factors.
Expansion Plans
There are plans to expand the AI application into other service lines like critical care. Eventually, WakeMed will roll the application out to all physicians and advanced practice providers. "Currently, we’ve implemented Regard primarily with our hospitalist team, since they handle the majority of inpatient documentation," Kirk said. "These clinicians still review and finalize the information, but the AI application dramatically reduces the time needed to gather and organize data, enabling them to focus more on clinical decision making."
Results
Despite being early in its documentary accuracy journey, WakeMed’s results have been impressive. "Using the AI application has led to $9.3 million in claims paid that might have been denied," Kirk reported. Additionally, this has resulted in $871,000 in new revenue for Medicare Severity Diagnosis-Related Group. There also has been a 3% improvement in severity of illness, helping clinical teams recognize the full clinical picture and leading to more tailored, appropriate care plans.
Quality Scores
The technology also has led to a 3.6% improvement in CC/MCC capture rate, which contributes to more accurate Hospital Compare and CMS star ratings, which can affect public perception and reimbursement. "The technology helps WakeMed to directly address the documentation challenges physicians face within the hospital," Kirk said.
Advice for Others
One of the biggest hurdles Kirk has seen when considering the adoption of AI-powered clinical insights technology isn’t technical – it’s cultural. "Many physicians still view the chart primarily as a tool to tell the patient’s story, and they may resist using tools that focus on documentation for risk adjustment, coding or revenue purposes," he observed. Explaining why documentation improvement is important is key in adoption.
Involving Physicians
Kirk encourages provider organizations to involve physicians early on in the process, show them how the technology works, and demonstrate clearly and directly that it works to improve patient care and not just help the hospital. "Accurate documentation isn’t just about reimbursement, it’s about ensuring continuity of care and giving the next clinician the full picture of the patient’s condition," he concluded. "Focus on building trust, showing value and integrating the AI technology in a way that doesn’t replace but supports the physician."
Conclusion
In conclusion, WakeMed Health & Hospitals has successfully addressed its documentation accuracy challenges by implementing an AI-powered clinical insights platform. The health system has seen impressive results, including improved documentation accuracy, enhanced coding and revenue capture, and a reduction in physician burnout. By involving physicians in the process and demonstrating the value of the technology, WakeMed has been able to build trust and show the benefits of AI-powered clinical insights.
FAQs
- What was the main challenge faced by WakeMed Health & Hospitals?
WakeMed faced a significant challenge regarding its electronic health record, needing to improve the accuracy of documentation without increasing physician burnout. - How did WakeMed address the challenge?
WakeMed used a three-pronged approach that included data, people, and technology components, including the implementation of an AI-powered clinical insights platform. - What were the results of implementing the AI-powered clinical insights platform?
WakeMed saw impressive results, including $9.3 million in claims paid that might have been denied, $871,000 in new revenue, and a 3% improvement in severity of illness. - What advice does Dr. Kirk have for other healthcare organizations considering AI-powered clinical insights technology?
Dr. Kirk encourages provider organizations to involve physicians early on in the process, show them how the technology works, and demonstrate clearly and directly that it works to improve patient care and not just help the hospital.
