Severity adjustment tools enhance documentation

Tools help explain variations in care

Health care providers have used severity adjustment tools at the state level since the 1980s. From both a cost-accounting and a planning standpoint, these statistical tools have helped providers define patterns of illness, establish accepted treatment protocols, and cut costs. The next step, says Darice Grzybowski, MA, RHIA, FAHIMA, is increasing the use of severity adjustment tools.

According to Grzybowski, national industry relations manager for 3M Health Information Systems in Salt Lake City, severity of illness adjustment allows health care providers to compare apples to apples. For example, "you can compare patients with clinically similar characteristics and similar resource consumption to see if they had similar outcomes," she says. "By using a severity adjustment software system, health care organizations can differentiate and distinguish a patient’s severity of illness and risk of mortality in comparison with other patients and help pinpoint variations in care."

One such software system is 3M’s proprietary All Patient Refined Diagnosis-Related Groups (APR-DRG) software, which Grzybowski says is currently being used by more than half of the states in the country to develop comparative provider report cards that help consumers evaluate local health care systems.

In Indiana, for example, APR-DRGs are utilized by the state hospital association but are also finding adherents at the point-of-care level. Carol Fridlin, RN, CPHQ, director of quality of management for St. Vincent Hospital in Indianapolis, is both a user and a proponent of severity adjustment software. St. Vincent uses both 3M’s APR-DRG and Care Management Science’s Manager product to sort and handle patient data. According to Fridlin, "severity adjustment lets us focus on the largest norm population rather than the extremes of the most ill or [the] very low-risk patients."

Because the larger group represents the majority of patients, understanding the data generated there can help practitioners establish better care paths. In addition, scrutiny of data also could help hospitals compare practitioners, such as comparing cardiologists to other cardiologists or to other types of physicians, says Grzybowski.

Because severity adjustment tools allow their users to account for degrees of illness, such as differentiating between an otherwise healthy patient who needs a knee replacement and one who has diabetes and needs a knee replacement, they give physicians a tool to explain why the first patient’s length of stay might be shorter than the second patient’s. Severity adjustment also takes into account varying mortality rates as they relate to patients’ overall health.

Fridlin recommends that hospitals looking to integrate severity adjustment tools approach it from two directions: "Look for your physician champions, and look for high case volume," she says. "If you don’t have a friendly practitioner group associated with the highest-volume population, start with the second-highest one." Happily for St. Vincent, the high-volume area of orthopedics also offered physician groups that were open to severity adjustment.

Physician participation is a must in order to establish a severity adjustment program that works, says Fridlin. Once physicians understand that severity adjustment tools provide usable data, they tend to support the tools, she says. "Physicians like [severity adjustment] because it provides comparison outcomes in like patients and gives added value to improved documentation," she explains.

The Chicago-based American Health Information Management Association (AHIMA) lists improved documentation as one of the "Characteristics of Best Practice Efforts" in the organization’s "Practice Brief: Best Practice in Medical Record Documentation and Completion." This brief encourages "transcriptionists and/or coders to translate information into structured (standardized) data," emphasizing that "universally coded patient data, as opposed to free text, is ideal because it makes each element of patient documentation available for both concurrent decision support and retrospective analysis of practice patterns."

After getting the physician champions on board and deciding on a focus area, hospitals new to severity adjustment still have to decide which proprietary tools to use. Fridlin suggests forming a team to research vendors and software while also seeking to answer critical questions about how your hospital plans to use the system. Such a team should include physicians, nurses, quality/performance improvement personnel, and computer services people, among others.

While she recommends looking at lots of software options, Fridlin encourages search groups to see what capabilities they may already have in-house. "Some of the hospitals in Indiana already had the APR-DRGs in their hospital but didn’t know it was there," says Fridlin. Needless to say, adding to existing systems can be much less expensive than buying a new system.

Also remember that the finest system in the world won’t deliver if people don’t know how to use it. "When you’re purchasing, make sure you budget for ongoing education," Fridlin says.

St. Vincent began using severity adjustment tools to evaluate orthopedic patients in the early 1990’s. As a result, the hospital has been able to reduce average length of stay from eight days to three days for a majority of patients undergoing major joint surgery. Along the way, "we have improved our care paths and seen an improvement in documentation," says Fridlin.

Although Fridlin says she can’t imagine not using severity adjustment tools, she says the tools work better in some areas than others. "We are using severity adjustment to improve care and outcomes for heart failure, stroke, and orthopedics," she says. However, "a place where severity adjustment systems are not popular is obstetrics. OB is already standardized," she notes.

Despite the potential and actual benefits of severity adjustment tools, they haven’t yet taken hospitals by storm. Grzybowski suspects that at least part of this hesitancy stems from users’ bad experiences with earlier models, which were created as "black boxes," meaning that the logic behind the formulas was hidden and unavailable to users. "Physicians found these types of systems to be unacceptable. They want to be able to scrutinize the logic behind the severity ratings for their patients," she says. "APR-DRGs are a completely open system. Users receive a three-volume definitions manual that contains all the logic. Today’s tools also have sophisticated report-writing engines to help users present the data in an understandable and valuable fashion," says Grzybowski.