White Paper: Documentation and Data Management Strategies for Improving AUC Integrity

Appropriate use is in the spotlight as the American College of Cardiology (ACC) seeks to close gaps and expand guidelines in response to an acceleration toward performance-based reimbursement models. Specifically, the first updates have been issued to the three-year-old coronary revascularization appropriate use criteria (AUC), and guidelines have been expanded in response to changes in medical evidence and clinical practice.
However, barriers remain that may limit efforts to fully utilize AUC to drive down costs and increase the quality of cardiovascular services by ensuring appropriate use and advancing the practice of evidence-based medicine. Specifically, documentation weaknesses and inconsistent data collection impact the integrity of the metrics against which appropriate use is measured.

Eliminating these obstacles has taken on greater urgency in the evolving reimbursement environment. The reality is that while AUC were explicitly not established for adjudicating payment, they are being used that way, albeit unofficially.i Combine that with expectations that the Centers for Medicare and Medicaid Services (CMS) and private payers may eventually use AUC for development of reimbursement strategies, and it becomes clear that quick action must be taken to ensure its integrity.ii

Addressing a Changing Environment

ACC first issued AUC for coronary revascularization in 2009. The idea was to capture and track key determinants of procedural appropriateness, including acuity of procedure, symptom severity, degree of ischemia on noninvasive testing, medical therapy and coronary anatomy. This would, in turn, provide hospitals with the means with which to compare their outcomes against peer facilities nationwide.

In early 2012, the ACC updated those AUC, marking the first time criteria had been updated since the initial guidelines were defined.iii The update closed gaps uncovered in the process of mapping the original AUC to the CathPCI Registry in preparation for inclusion of AUC metrics.iv, v

That was followed closely by the issuance of the first set of AUC for diagnostic catheterization. In both cases, the actions were in response to changes in medical evidence and calls for greater adherence to evidence-based medicine practices in the wake of highly publicized cases of inappropriate stent and implantable cardiac defibrillator (ICD) use.vi
Also factoring into the ACC's decision to address diagnostic catheterization are several studies that identified high rates of procedures that failed to meet appropriate use guidelines. In one, researchers examined 166 potential indications that could warrant a diagnostic catheterization procedure and found that fewer than half should be classified as appropriate. Specifically, 75 were classified as appropriate, 49 as uncertain, and 42 as inappropriate. Other research findings include:

  • Just 36 percent of non-emergency angioplasty patients qualified as appropriate candidates, while nearly 50 percent were classified as uncertain and 14 percent were inappropriate.vii
  • Approximately 30 percent of stress echocardiograms and single-photon-emission computed tomography myocardial perfusion imaging (SPECT MPI) studies are considered inappropriate or are questionable.
  • More than 20 percent of ICDs and 40 percent of cardiac resynchronization therapy (CRTs) implanted in heart-failure patients are unwarranted.
  • Nearly 12 percent of elective percutaneous coronary interventions (PCIs) are classified as inappropriate and nearly 40 percent as uncertain.viii

"These new guidelines represent a notable evolution in focus of appropriate use," wrote The Advisory Board Co. "Highly public cases of inappropriate stent and ICD use, coupled with a number of studies identifying failures to adhere to evidence-based guidelines, have prompted unprecedented focus on hardwiring appropriate use in the cardiovascular terrain. To this point, however, these efforts have largely centered around either non-invasive imaging technologies such as echocardiograms, or on treatments such as ICD implantation and PCI. By tackling diagnostic catheterization, the authors have expanded the industry's focus on providing evidence-based practice even further."

But while the updates filled in critical gaps and moved AUC closer to its goal of accurately monitoring and measuring the appropriateness of cardiovascular procedures, data integrity challenges remain. The first step in addressing those issues is to shore up weaknesses in procedure documentation, which drives appropriate use metrics.
"We devote enormous energy and space with very technical details without sometimes in an entire chart ever saying why a patient had the procedure in the first place," said John Spertus, M.D., M.P.H., Clinical Director of Outcomes Research for Saint Luke's Mid America Heart Institute. "...Clinicians should think about tools and strategies to repeatedly assess the appropriateness in real time and at the very least be very explicit about why they're doing the procedure."

Data Integrity Concerns

A number of factors are driving ongoing concerns about the quality of AUC data being collected and reported by cardiovascular service providers. According to the ACC Foundation/American Heart Association Task Force on Clinical Data Standards, when "compared with more mature or naturally discrete types of data concepts such as laboratory results, interoperability of data representing information acquired historically or during a patient encounter (e.g., history, symptoms and signs of heart failure) remains rudimentary."ix

Two reports from the Accreditation for Cardiovascular Excellence (ACE) lend credence to these findings. Both showed that the most common problems are deficiencies in documentation and recordkeeping. The first involved reviews of 122 randomly selected angiography cases from five ACE centers, including at least three cases from every interventionist. While lesion characterization and adherence to appropriateness standards were generally excellent, documentation of imaging studies was poor. This led researchers to conclude that inadequate documentation of variables required for risk adjustment and evaluation of appropriateness was common.

The second involved the findings of process reviews of 147 records of catheterization procedures at seven ACE centers. While more than 95 percent of the charts met The Joint Commission reporting requirements, many did not document complications, radiation and fluoroscopy time. Biomarker status was recorded in only 61.7 percent of the records, and information on readmission, post-discharge mortality or the possible development of contrast-induced nephropathy was not available in approximately 72 percent of the records. New York Heart Association (NYHA) heart-failure classification was not recorded in 41.6 percent of the records.

As a result of documentation deficiencies, data submitted to the National Cardiovascular Data Registry (NCDR) could not always be validated. This prompted ACE to recommend that more attention be devoted to the documentation process, as well as to the training of data abstractors. Also recommended was greater involvement of physicians in data review before and after the cases are submitted to NCDR.

"The variations have been much more dramatic than we thought," said ACE's Bonnie Weiner, M.D. "And most of those revolve around the documentation. Many of you have heard 'if you don't write it down, it didn't happen.' And if we're going to use the data and expect our staffs to be able to complete the clinical data sets that we all think are so critically important, we need to make sure that we write down and somehow document the kinds of things that go into those data sets, so that we know that the way we're being evaluated is in fact valid and complete."x

A simple, yet powerful, reason for data integrity issues is a lack of comprehensive health IT for cardiology providers. KLAS reports that 45 percent of providers consider their cardiology systems to be incomplete. Of those, the majority (51 percent) cited clinical reporting as the main missing piece. Further, of the providers who indicated they planned to leave their current cardiology vendor because "something is missing," more than half mentioned a lack of reporting functionality.xi

As a result of this technology gap, many cardiology providers continue relying on primarily manual, redundant and inefficient paper-based processes to capture and report AUC data points. These manual processes are fraught with the potential for human error, and the issues are exacerbated by the complex nature of cardiology documentation, which can lead to gaps resulting in double-digit error rates. Indeed, an internal audit conducted by one hospital found error rates as high as 90 percent in its cardiac catheterization lab, while another found an average error rate of 70 percent in cardiology peripherals.xii

Manual documentation hinders the efficient, accurate and comprehensive capture of structured and compliant data and doesn't enable querying of discreet elements once the data are in the reporting system. The end result is inconsistent and incomplete data that, once reported, do not advance the goals of initiatives like AUC by making it difficult to perform effective benchmarking and meaningful comparisons.xiii

Strength Through Automation

There are a number of options for enhancing the tracking and prospective assessment of AUC, including spreadsheets, flow charts and even a quality improvement toolkit and webinar from the Society for Cardiovascular Angiography and Interventions (SCAI).xiv However, these approaches do not address the weaknesses inherent in a manual documentation process.

The most efficient and effective approach is to leverage automated cardiology procedure documentation and coding software, which can overcome both data quality and standardization issues as well as the challenges presented by limited internal resources.

Intuitive procedure documentation software allows many of the required data points to be collected directly from procedure notes, lessening the need for manual intervention and eliminating duplicate data entry. It also enables limited resources to be refocused on other core responsibilities, increasing productivity and potentially accelerating patient throughput. When documentation software is interfaced with other systems, more data points are collected without any additional resources. Automation also ensures standardization of data, and because specific AUC points can be flagged, reporting gaps can be eliminated.

In recognition of the growing emphasis being placed on AUC and other quality metrics, a small number of vendors have introduced tools that integrate with procedure documentation and coding software to further enhance data integrity and streamline reporting.

They work by first guiding physicians through the process of capturing all required data elements, then organizing that data into a specific format that can be transmitted directly to various registries. For example, the software would highlight data required by the NCDR, including patient demographic and admission data, hemodynamic system data, and clinical documentation data including diagnostic and PCI information. It would then feed the data automatically into the reporting tool for submission.

By making AUC data requirements an integral part of a physician's documentation workflow, automation tools increase the efficiency with which reporting is accomplished. They eliminate redundant data entry, which improves data quality and accuracy, and allow for the easy review, augmentation and modification of collected information. Finally, the tools enable real-time reporting on quality metrics, eliminating the need to wait for quarterly AUC/ACC reports for comparisons.

Maximizing AUC Potential

To realize the full impact AUC tracking can have on the provision of high-quality, appropriate care, the data being reported must be structured, complete and accurate. Leveraging technology to automate procedure documentation and the capture and reporting of AUC data points will not only enable the program to achieve its objectives, but also ensure that cardiovascular service providers trust the data being utilized to benchmark performance and influence change.

i Theheart.org (Producer). (2012, April 30). Are appropriate-use criteria for coronary revascularization advancing patient care?(Session in ongoing series) [Streaming video]. Retrieved from http://www.theheart.org/editorial-program/1385783.do?utm_campaign=newsletter&utm_medium=email&utm_source=20120511_EditoDiscussion_EN.

ii Nemani, K. (2012, March 16). "Three years later: The PCI appropriate use criteria in review." CardioSource World News. Retrieved from http://www.cardiosource.org/News-Media/

iii The Advisory Board Co. (2012, February 1). "ACC releases updated appropriate use criteria for coronary revascularization." Cardiovascular Rounds. Retrieved from http://www.advisory.

iv National Cardiovascular Data Registry. (2012, May). "The ACC announces availability of AUC metrics." News and Views. Retrieved from http://www.vertexcommunication.com/acc/NCDR_News_and_Views_May.htm.

v National Cardiovascular Data Registry. "FAQs for CathPCI Registry Outcomes reports" [PDF download]. CathPCI Registry. Retrieved from http://www.ncdr.com/CathPCI/Libraries/NCDRDocuments/FAQs_for_CathPCI_Registry_Outcomes_Reports.sflb.ashx.

vi The Advisory Board Co. (2012, May 14). "Appropriate use criteria for diagnostic cath." Cardiovascular Rounds. Retrieved from http://www.advisory.com/research/cardiovascularroundtable/cardiovascular-rounds/2012/05/appropriate-use-criteria-for-diagnostic-cath.

vii The Advisory Board Co. (2012, May 25). "Only 36% of angioplasty patients meet the procedure's criteria." The Daily Briefing. Retrieved from http://www.advisory.com/Daily-Briefing/2012/05/25/Only-one-third-of-angioplasty-patients-meet-procedures-criteria.

viii Pfennigner, D. (2011, December 8). "How appropriate use will impact cardiovascular growth strategy." The Daily Briefing. Retrieved from http://www.advisory.com/Daily-Briefing/2011/12/08/How-appropriate-use-will-impact-cardiovascular-growth-strategy.

ix Wentraub, W.S., Karlesberg, R.P., et al. (2011, July 5). "ACCF/AHA 2011 key data elements and definitions of a base cardiovascular vocabulary for electronic health records: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards." Journal of the American College of Cardiology, 58, 202–222. Retrieved from http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.05.001.

x Miller, R. (2012, May 13). "New angiography appropriateness criteria are SCAI's latest 'quality tool.'" HeartWire. Retrieved from http://www.theheart.org/article/1397759.do?utm_campaign=newsletter&utm_medium=email&utm_source=20120518_TopStories_EN.

xi Staff report. (2012, March 19). "Cardiology PACS and consolidation: Will a leader emerge?" Imaging Technology News. Retrieved from http://www.itnonline.com/article/cardiology-pacsand-consolidation-will-leader-emerge.

xii Benson, S. (2010, March 12). "Top 5 documentation and coding challenges confronting hospital specialty service lines." Becker's Hospital Review. Retrieved from http://www.beckershospitalreview.com/news-analysis/top-5-documentation-and-coding-challenges-confronting-hospital-specialty-service-lines.html.

xiii Deas, T. (2012, February 5). "Tracking quality measures." Executive Insights. Retrieved from http://healthcare-executive-insight.advanceweb.com/Features/Articles/Tracking-Quality-Measures.aspx.

xiv Society for Cardiovascular Angiography and Interventions. SCAI Quality Improvement Toolkit (QIT) & Webinar Series [Software and webinar]. Retrieved from http://www.scai.org/qit.