Health Information Management

Tip: Thinking of adding quality core measure review to the CDI role? Be aware of the challenges

CDI Strategies, April 29, 2010

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Despite the inclination of many hospital administrators to mechanize documentation and abstraction of quality measures, Kristen Geissler, MS, PT, MBA, CPHQ, associate director in the Healthcare Clinical Economics Practice at Navigant Consulting, Inc., in Baltimore, hasn’t heard of anyone able to fully automate this process.

“There are just too many elements that require a human interaction,” she said during the February 2 ACDIS audio conference, Quality Measures and CDI: A Case Study and Best Practice Approach for Success. “Of course whenever the so-called human element is involved, there needs to be an awareness of human fallibility.”  
And while abstraction rules do exist they change frequently presenting a challenge for the unfamiliar reviewer. “It’s quite difficult to stay on your toes and stay up to date,” she says. This can be a particular problem for CDI programs looking to add core measure abstraction duties to their other CDI tasks.
“Quality control is a question that comes up a lot,” says Geissler. “How do we know that the person abstracting the data is gathering the data in the same way (as efficiently) as another?”
While CMS conducts core measure audits, it only pulls five cases per year from across all measure sets, looking for at least an 80% agreement rate. “It’s not statistically significant but it is an element of quality control,” Geissler says.  
Programs looking to incorporate core measure review and data abstraction roles into CDI specialists’ job responsibilities should be sure to build internal auditing measures into their overall plan. Adding responsibilities such as core measure review and auditing abstraction records for compliance also means additional staff time, says Geissler.
Learn more about incorporating core measure review in the April edition of the CDI Journal.

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