MedCDI: A technology-based documentation and quality improvement initiative in neurosurgery

Area of Science:

• Neurosurgery
• Health Informatics
• Quality Improvement

Background:

• Clinical documentation significantly impacts the accuracy of coding, mortality predictions, and expected length of stay (LOS) for neurosurgical patients.
• These factors are critical components of healthcare quality metrics.
• Gaps in documentation can lead to inaccurate assessments of patient care and resource allocation.

Purpose of the Study:

• To identify specific documentation deficiencies in neurosurgery that affect quality metrics.
• To develop targeted interventions, including a mobile application and educational video, to improve documentation accuracy.
• To enhance the reliability of neurosurgical quality metrics through better data capture.

Main Methods:

• Analysis of Medicare Severity Diagnosis-Related Groups (MS-DRGs) and expected LOS using Vizient software for spinal pathology, brain tumor, and subarachnoid hemorrhage (SAH) patients.
• Conducting chart reviews to identify variables missed by providers or coders.
• Data collected from January 2019 to August 2021.

Main Results:

• Chart reviews revealed significant documentation gaps: 43% of spine, 75% of brain tumor, and 92% of SAH patients had at least one additional variable impacting LOS.
• An average of 1.25, 1.75, and 2.89 new variables were identified per patient in spine, brain tumor, and SAH cases, respectively.
• Recalculated expected LOS increased by an average of 0.86 days (spine), 3.08 days (brain tumor), and 6.46 days (SAH).

Conclusions:

• Accurate patient care documentation is essential for improving neurosurgical quality metrics, including expected LOS, mortality, and cost estimates.
• Identified missing variables highlight a clear opportunity for neurosurgical documentation improvement.
• A novel approach using a mobile application and educational video targets these specific documentation gaps to enhance neurosurgical quality metrics.