Background: Accurate documentation of the patient’s diagnoses helps to reflect the severity of illness which has several downstream impacts: clinical outcomes data, risk stratification, hospital quality metrics data such as readmission and mortality index, hospital reimbursement. For this reason, our health system has various ongoing initiatives on clinical documentation to improve the specification of certain high yield diagnoses. Recently, atrial fibrillation was recognized as an area of opportunity at our quaternary care institution. There are five classifications of atrial fibrillation: paroxysmal atrial fibrillation, chronic atrial fibrillation, persistent atrial fibrillation, longstanding persistent atrial fibrillation, permanent atrial fibrillation. Each classification except paroxysmal atrial fibrillation is considered a comorbid condition (CC) according to the Centers for Medicare and Medicaid Services (CMS) guideline.
Purpose: We aimed to raise awareness and improve the physician and advanced care providers’ (ACP) documentation of atrial fibrillation specificity.
Description: A series of meetings took place with the representatives of the Clinical Documentation Improvement (CDI) team, Informatics Team, physician leads from the Department of Cardiology and Hospital Medicine to develop strategies around education and streamlining the documentation process. We provided educational sessions focusing on the importance of this initiative and the definition of five classifications of atrial fibrillation to full-time hospitalists, voluntary attendings, Internal Medicine residents, and Advanced Care Providers (ACP). One anticipated challenge for the physicians and ACP we hoped to address was the difficulty with memorizing the definition of each atrial fibrillation classification. To mitigate this barrier, we created macros with templated text in our electronic medical record that outlined the definition of each atrial fibrillation classification. This facilitated the process by which any physician or ACP can easily incorporate the macros into their note to review the corresponding definition of each atrial fibrillation classification and select the one that is pertinent to their patient. We instituted a weekly reminder email to members of the inpatient faculty Cardiology consult team and conducted random chart audits to provide feedback to physicians if atrial fibrillation diagnosis was unspecified in their documentation. This direct feedback mechanism helped to reinforce education and allowed an opportunity for the physicians to make modifications in their documentation in real-time.
Conclusions: Before this initiative, the average compliance rate for the atrial fibrillation specificity in our documentation was 54% in 2020 through the early part of 2021. Since the implementation of our strategies in April 2021, we have seen a steady improvement in our atrial fibrillation specificity documentation compliance rate. Of the total cases with atrial fibrillation diagnosis, 63.9% were specified in April and 75.3% in October 2021 with an average of 68.4% compliance rate over a span of seven months. The medical patients cared for by the full-time hospitalist and the voluntary group together make up approximately 56% of the total cases of atrial fibrillation in our hospital and they proved to be the biggest driver in the overall improvement with an average of 70.7% compliance rate for the voluntary group and 76.6% for the fulltime hospitalist group since April through October 2021.