Podcast – The Importance of Clinical Documentation in Value-Based Kidney Care

This episode of Kidney Health Connections highlights the shift from fee-for-service, where nephrologists could focus mainly on the renal aspects of patient care, to value-based care models, where providers must take a more holistic view of the patient. Naz Urooj, senior vice president of quality and clinical documentation at Interwell Health, explains that risk adjustment models rely on ICD-10 codes to assess patient complexity and predict costs, meaning nephrologists need to thoroughly document all relevant comorbidities to paint a complete picture of patient complexity, ultimately enabling providers and payers to direct resources to the patients who need them most.

As Interwell Chief Medical Officer Dr. George Hart attests from his own experience caring for patients, clinical documentation is a new skill for nephrologists. This episode dives into tools and strategies to support clinical documentation, including specialized electronic health record (EHR) systems designed to make the right data easily accessible and provider training to ensure accurate coding.

Transcript:

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift to value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: Patients with kidney disease rarely face kidney disease in isolation, and unfortunately, they're living with multiple comorbidities, such as diabetes, hypertension, congestive heart failure. And for us as clinicians to deliver effective, holistic care, we need to accurately capture the clinical complexity of these patients.

What that means is it's critical for providers to document those conditions accurately. This is especially true in value-based kidney care, since we commit resources based on this complexity to those patients who need it. Naz Urooj, our vice president of clinical documentation and quality here at Interwell, joins us today for a conversation on the importance of this clinical documentation and what it means for value-based kidney care.

Naz, good to see you. Thanks for coming today. Welcome.

Naz Urooj: Thank you so much for having me, Dr. Hart. I'm so excited to be here.

Dr. George Hart: Well, good. Well, let's just get started, okay?

Naz Urooj: Absolutely.

Dr. George Hart: I was a nephrologist for 30 years, and I lived through paper charting, the rollout of electronic healthcare records. But my career was, for the most part, in a fee-for-service world, chopping wood, one patient in front of me. And I understood individual complexity, but not the importance or need for having this captured in a way, because, frankly, it didn’t mean anything. I might even have been a little resistant to try and do that. I'm sure that you may see that when you go out into the world and deal with nephrologists, but how about taking a minute and giving us an overview of why this is important in this shift from fee-for-service into value-based care?

Naz Urooj: Absolutely. And thank you so much for actually sharing your experience. I know it's a paradigm shift for a lot of providers as they move from fee-for-service into value-based care. But I'm going to ask you this: have you heard of this phrase called, “My patient is sicker than yours?”

Dr. George Hart: Only because my patients were sicker than anybody else's.

Naz Urooj: That's the question that we constantly get as providers are moving from fee-for-service into value-based care. In fee-for-service, providers were getting paid for the quantity, right? Like they're getting paid for the service they provide. In value-based care, that's a paradigm shift. The patient is treated at a holistic level, so you have to really understand the patient as a whole. And then, to top this off, the reimbursement model essentially is tied to how sick your patient is overall and the holistic view of that patient. And so that shift has been a change for a lot of our providers.

Dr. George Hart: I get it. I understand it. I understand it a lot better now that I'm on this side of the curtain. How are you leaning in with physicians to help them understand this? And what does it take for them to finally, for the light bulb to go off?

Naz Urooj: That's, again, a great question, but I'm going to take a step back for us. I'm going to talk a little bit about what is risk adjustment, because that is like the core of understanding what is happening and why some of this is important. Risk adjustment is a fiduciary model. It's a predictive model that CMS has put in place to understand the severity of illness of a patient. And what CMS has done is that of the 50 million Medicare patients, they have assigned a numeric value to understand how sick that patient is. And they've calculated it a certain way. They have taken their demographics, things like age and sex, as well as Medicare/Medicaid status. And then they added the ICD-10 framework, which is essentially taking all of these 10,000 ICD-10s, and they categorize them in these different categories, and they're essentially comorbidities.

So they take the age, sex, Medicare/Medicaid status, plus these comorbidities, and they come up with a numeric value that essentially predicts how sick that patient is. So you have to understand that piece to really know what is really going, how to be successful in value-based care, because the risk adjustment component is so critical as part of the journey.

Dr. George Hart: So is every clinical condition equal in its impact on cost and complexity, or are there differences that we need to understand?

Naz Urooj: There are absolutely differences we need to understand. What CMS has done is, I mean, this model has been here for the last several decades, and it's, again, it's not going anywhere. They have taken these 10,000 ICD-10s, and they put them in these categories to say, OK, these are the ones that essentially are in the model that are risk adjustable. So it's important to know the complexity of the patient. And in our world of nephrology, our patients already are extremely complex, and they come with comorbidities. And these comorbidities are part of the model, and it's important to know which ones they are.

Dr. George Hart: As I think about how sick a patient is, if they have heart failure, they have cardiovascular disease, in my mind, they're more likely sicker than if they have some other issue. Am I thinking about it in the right way?

Naz Urooj: Absolutely. But in the world of fee-for-service, a lot of providers, you know, like yourself, you looked at that kidney patient and looked at probably the causational conditions of that patient. Could be, let's say, diabetes, heart failure, hypertension, and may or may not have focused on any other possible conditions that the patient may or may not have. Because you didn't have to think about it. You only had to worry about their renal conditions.

And so in this world of fee-for-service, as you transition to value-based care, you're looking at the patient holistically. So you're having, our providers today are having to spend a lot more time talking to that patient, understanding what is, what else is, going on outside of the renal.

Dr. George Hart: Well, that sounds like a good thing, right?

Naz Urooj: Absolutely.

Dr. George Hart: For us to be a little more holistic in how we view the needs of a patient.

Naz Urooj: Absolutely.

Dr. George Hart: Great. So in your view, would you say that this migration toward this concept is going to improve the overall care for patients?

Naz Urooj: Well, yes. I mean, our whole goal here is to drive better patient outcomes, right. So what happens in the world of nephrology today is that, and you've experienced it yourself, where that patient, when they come to a nephrologist, especially our end stage renal patient, who are extremely complex, extremely sick already, they come to the nephrologist and they treat you as a primary care doc. You already are seeing that patient two, maybe three times a week, you already are building that relationship. So it absolutely is a great way to really understand what is happening to that patient. And more and more of our patients are treating that nephrologist as a primary care doc. And so ultimately it is driving better patient outcomes and as well as better patient engagement.

Dr. George Hart: I get it. I believe it. What's the reception in the nephrology community as you go out and do this hand-to-hand combat, practice by practice, doctor by doctor? Are you finding resistance, or what does it take to help convert these guys to a different way of thinking?

Naz Urooj: It's challenging, to be quite frank and transparent about that. The reason why is because the nephrologist, unlike any other specialty, unlike, let's say, primary care doc, you experience this yourself, right, where you probably are getting up early in the morning and starting your day, probably in a hospital, and then going to a dialysis unit, and then maybe may or may not end your day either back at the hospital or in your own clinic.

And so that shift from one space of service to another, a lot of times those systems are not talking to each other. So our challenge with our nephrologists today is, well, I'm essentially used to documenting two or three things looking at the patient from a renal perspective, and that's it. Now you're asking me to do something more than that. Meanwhile, my systems are not talking to each other.

And so how we have overcome that at Interwell Health is we have taken our systems and solutions and we try to embed workflows at point of care to make it easier for our nephrologists to look at those comorbidities at point of care.

Dr. George Hart: Let me get this straight. In full transparency, Interwell has its own electronic healthcare system, Acumen, built on Epic. Seventy percent of our providers use Acumen. You're partnering with Acumen to help physicians navigate this?

Naz Urooj: Exactly, yes. And I get really excited about this part because what we have been able to overcome is, at point of care within Acumen Epic Connect system, we have been able to build functionality for our providers where they're able to look at that information as they see the patient face to face. We have been able to take all sorts of data that is behind the scenes, like claims data, through Epic. Epic has their own functionality as well. We've been able to turn a lot of those features on so that information is readily available for our providers at point of care.

Dr. George Hart: I'm seeing a patient. I'm doing what I would normally do. There are prompts that are going to come up in the electronic health care record system that would tell me that I have or haven't done a particular addressing of a problem. Is that kind of how it goes?

Naz Urooj: That's exactly how it goes. And so, you know, again, pretend like you are a provider who is actually seeing.

Dr. George Hart: I don't have to pretend. I was.

Naz Urooj: Oh, yes, that's right, you were a provider. But, you know, just think back, like a couple years ago, you're seeing a patient. Absolutely. So the provider is sitting in front of the patient. The prompts are right there for you. It tells you what you have to address and what you haven't addressed yet. But what it does for you is that it allows you to ask questions that you may or may not have asked before, or may or may not know about the patient historically.

Let's assume that patient today, you know, has, you probably look for diabetes, you probably look for hypertension, you probably look for heart failure, but you may or may not ask them about amputation, but that may pop up for you to ask some questions around, whether, what type of amputation.

So it really gives you that point of care visibility of that patient.

Dr. George Hart: Given this interconnectivity that Acumen has with Epic, if a new diagnosis is entered into the system by another outside provider, does that become visible for me during my clinic visit so I get a chance to assess that new problem?

Naz Urooj: Exactly. So I mean, you are basically saying the words of what the system does. If anything new comes up on that patient, let's say depression, which is very prevalent to our patient population, that will pop up. You are able to see that information, right at point of care. Anything new that comes in, anything that we see from claims come in, we push that information right into our, our system.

Dr. George Hart: Again, to me, this is fascinating because what you're really describing is this actually works together to break down the silos and the fragmented nature of healthcare today and kind of enable a nephrologist to be the holistic physician that the patient needs to be successful.

Naz Urooj: Absolutely.

Dr. George Hart: Did I get that right?

Naz Urooj: You got it. It's perfect. Perfectly said.

Dr. George Hart: Okay, well, this is exciting because I can tell you, in my old world, you know, it was very fragmented and very difficult to have this communication. And none of this was ever explained in the way that you're explaining it. And certainly I didn't have that connectivity with my native electronic record system. So this is fascinating.

Naz Urooj: I think you missed out, Doctor Hart.

Dr. George Hart: I think I did. I might still be in private practice if I had worked with Acumen. We talk about physicians a lot in this, and they certainly are important. Is there a role where advanced practitioners can participate in this documentation too?

Naz Urooj: Absolutely. So it's not just in hands of the nephrologist. It's not fallen on the responsibility of just the nephrologist or the physician. We encourage at Interwell Health for practices who have advanced clinicians or have extenders within their practice to really be utilized to assist with additional care that the patient may need, additional follow up that the patient may need because of this clinical documentation activity.

As a matter of fact, we have a lot of our practices who embed extenders, nurse practitioners, APPs, who do things like annual wellness visits or do things where they're having to follow up with the patient and they can actually document. And many of them who are using our Epic systems are documenting in Epic today.

Dr. George Hart: Yeah. Good. You travel the country, east coast, west coast, north, south, large practices, small practices, Acumen, not Acumen. What are the challenges that you see as you kind of canvass the country trying to spread the word?

Naz Urooj: Yeah. So there are quite a bit of challenges. I mean, we just talked a little bit about the system, right? Like, the systems are fragmented many times. They're not talking to each other. The other challenge that we see is as providers are moving from fee-for-service into value-based care, it's a complex model. Right? So you have these 10,000 ICD-10s that are in the model. We're not asking our providers to know every single ICD-10 code.

And just like yourself, you didn't go to medical school to learn coding. You went to medical school to treat patients. We are having to educate the providers, their billing staff, their administrative staff, their APPs, their extenders, and understanding the model and educating them 101. Sometimes it's a 101 conversation around why this is important. What are the outcomes? What are the outcomes we should be anticipating because of this work? And the challenges we're seeing is like, yes, there's systems, but then, as well as just not understanding the model.

So we're spending a lot of our efforts on education, providing them one on one feedback, side by sides. We will meet the provider where they are at. The thing that's clicking is that we're not starting with the entire model and saying, “You’ve got to know everything.” We're saying, “Let's build your muscle mass.”

Right. We're going to start with what's most prevalent to renal, and then as you get comfortable with prevalent to renal, then let's start to look for other things. And we've had providers who have found active cancer in our patient population they may or may not have even known or observed or found historically in the world of fee-for-service.

Dr. George Hart: Part of my goal and reason for leaving private practice and coming to Interwell was to kind of help practices make this transition from fee-for-service into value-based care, and to actually be able to confirm that they were delivering the quality care that all providers think we delivered. Do you have examples? You just gave one about finding cancer, but other examples of where this expanded approach to looking at the patient is reaping benefits and rewards?

Naz Urooj: Yes. So I have multiple examples, but I'll give you one that seems to stick a lot with our providers. As you already know this, right, our end stage renal population comes with, on an average, seven to ten comorbidities, and that patient is already very, very sick. And these comorbidities don't go away.

So let's just consider a patient, John. John is an end stage renal patient. You probably have seen this patient probably two to three times a week for multiple years. In the world of fee-for-service, again, you probably saw that patient and said, “OK, how's that patient doing? Are they showing up for dialysis? Are they getting their dialysis treatment?” May or may not have spent the time to really get to know what is happening to that patient holistically. And so in addition to, let's say, the patient John has kidney disease and also has heart failure, but let's assume this patient also has an amputation. Now, the risk of amputations or fall risk, possibly sepsis, that could also lead to other issues as well down the line for the patient.

In the world of value-based care, we have seen providers really address what is happening. Again, we're assuming amputation here. What is happening at home? Does a patient have the right flat surface? They're doing assessment on fall risk more than they did before. And so we're seeing better patient outcomes in this journey of value-based care where the providers are spending a lot more time and really driving quality of care end of the day.

Dr. George Hart: What I think you’re really talking about is an ability to devote extra additional resources to create a situation that prevents that patient from having an unnecessary hospitalization.

Naz Urooj: You said it well, exactly. That's right.

Dr. George Hart: Which is exciting.

Naz Urooj: Yes.

Dr. George Hart: Because it certainly didn't exist during my time as a nephrologist, for the most part.

Naz Urooj: Yep. We want to keep these patients out of the hospital.

Dr. George Hart: Yeah, absolutely. Any pitfalls in doing all of this? I mean, I've certainly read of other organizations being fined for what was thought to be misappropriate handling of all this. What are you doing? What is Interwell doing to make sure that we are approaching this capture of complexity in the right way?

Naz Urooj: Yes. So, you know, again, this is what makes me really excited at Interwell Health, is the things we have been able to build and develop. We want to accurately document, and we really make sure that our providers and their extenders are documenting things accordingly. So there are a few things we have put in place at Interwell Health.

We do have a program called educational chart review. So we do chart reviews on providers’ documentation. And there's side by side, one on one education happening behind the scene.

Dr. George Hart: And there are some set criteria that need to be met for documentation to be appropriate, right?

Naz Urooj: Absolutely. So there's, you know, CMS had some coding and documentation guidelines out there. We spent a lot of our energy in starting with the 101 basics of clinical documentation, and we cover a lot of details around what's called the M.E.A.T. criteria, essentially looking at the criteria that CMS has put in place to ensure that our documentation is meeting.

Dr. George Hart: Good. I can sleep better tonight knowing that you're doing all that. Great. So I'm going to pivot here for a second, Naz, because you do wear more than one hat, and you also help us oversee quality, and you work with our population health team. Can you maybe give us a little idea of what population health means at Interwell and what you're focused on?

Naz Urooj: Absolutely. The piece with the clinical documentation world is that it ultimately drives us to understand a lot of our disparities that occur in our population. So some of the strategies we are putting in place, or some are already in place, are looking at those social determinants of health, looking to understand where are some of the disparities within our population.

So, for example, we may have, you know, we have assessed to see, OK, we have assessment around transportation issues or food or medication access or healthcare access. So at Interwell Health, we have spent a lot of time in understanding our population, but we're not there yet. I think we're still learning more and more about where we're, about our population. And our long-term goal is to continue with accurate documentation so we can understand our disparities. That will allow us to really put in some long-term programs in place to address those inequalities, if they exist.

Dr. George Hart: Yeah, I mean, I keep reflecting on my own career, and what I found time and time again was the barrier to the healthcare that I wanted to deliver for a patient were these issues. It was the fact that they didn't understand a word I said, or they couldn't read, or they were so focused on being hungry, or they didn't have a place to live. You know, “Who cares what Dr. Hart's saying? I’ve got to figure out where I'm going to sleep tonight.” You know, these are overwhelming challenges that we need to work through.

Naz, as always, it's so good to see you, and thanks for helping shed some light on the importance of documentation and how we capture clinical complexity and what it means for our patients, our physician partners, and our payer partners.

And thank you for our listeners for tuning into Kidney Health Connections. If you have questions about anything we talked about today, and specifically us making the shift to value-based care and how to get clinical documentation right, please reach out to us at our website, interwellhealth.com. We hope you'll continue to follow the conversation by subscribing to Kidney Health Connections on the listening app of your choice.