Shelley C. Safian

Automatic triggers in your EHR system can be a reminder to physicians of certain CMS-supported care processes that can enhance your organization's patient care and help build its revenue streams.

At a Glance

  • Certain process-of-care measures advocated by CMS on its Hospital Compare web site can provide a basis for identifying patients who should be screened for certain medical conditions for which they are at high risk.
  • Automatic triggers built into an EHR can help physicians identify such patients and establish medical necessity for services that both improve patient care and increase revenue for the organization.
  • Such screenings also can help determine at the time of admission whether a patient has a major medical complication or comorbidity, which-if undetected-could have serious payment implications.

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) authorizes the Centers for Medicare & Medicaid Services (CMS) to reduce the Medicare annual payment update for hospitals that do not submit data for specific quality measures. The data reported by hospitals through this program, some of which are available to the public via CMS's Hospital Compare web site (, help beneficiaries and other consumers make more informed decisions about their health care.

Senior financial managers can use these clinical care data to spur patient care improvements that contribute to better patient outcomes while increasing revenue along the way. Achieving these results requires not the development of new knowledge, but a new perspective: By combining existing data with electronic support, financial professionals and other healthcare leaders can help to establish an internal system that is more efficient, more effective, and more profitable for the organization.

Triggers that Improve Outcomes-and Revenue

Hospital Compare currently provides information to consumers on 27 quality measures, including 24 clinical process-of-care and three clinical outcome measures, as well as 10 patient experience-of-care topics. Let's begin with a small selection of process-of-care measures that, when provided to a patient, can be set up to trigger a sequence of events that will proactively help the patient, the hospital, and the revenue stream.

The initial set of process-of-care measures includes the following admitting diagnoses:

  • Acute myocardial infarction (AMI), one of the leading causes of hospital admissions each year for Medicare beneficiaries, affecting about 1 million individuals
  • Heart failure (HF), the most common hospital admission diagnosis for patients aged 65 and over, resulting in more than 700,000 admissions each year
  • Community-acquired pneumonia (CAP), the cause of nearly 1 million hospital admissions each year

The process-of-care measure sets shown for these three diagnoses have one item in common: Smoking cessation advice and counseling should be provided to all patients who have a history of smoking. Attending physicians should ask patients with these diagnoses, "Do you smoke?" If the answer is "yes," the physicians should refer these patients to a smoking cessation program offered by the organization.

Such services qualify as medically necessary, and a referral to such a program is a simple way to increase revenue for your organization-as well as improve patient outcomes. Moreover, by establishing medical necessity, these patients could be referred to other services that could further improve outcomes while increasing revenue for the organization.

The facility's electronic health record (EHR) could be tagged to remind attending physicians to ask patients with these three diagnoses whether they have a history of smoking and, when the response is "yes," prompt the physician to recommend a consultation with an appropriate hospital professional. Adding this one question to the admission assessment performed by nurses upon admission to the floor also may lead to increased referrals when nurses alert physicians to a positive response.

Certainly, implementing these strategies will require the cooperation of the clinical team. However, when all departments within one facility can work together for the good of the patient and the good of the hospital-in the short term and long term-everyone benefits. And that is what is at the heart of this concept.

A Basis for Preventive Measures

A patient's history of smoking noted at the time of admission for AMI, HF, or CAP also can raise a concern about other potential smoking-related medical conditions, and there may be a medically sound reason that the patient should consider undergoing a screening for these conditions as well. Consider, for example, that: 

  • Ninety percent of lung cancer deaths in men and almost 80 percent of lung cancer deaths in women are caused by smoking.
  • Cancers of the bladder, oral cavity, pharynx, larynx, esophagus, cervix, kidney, lung, pancreas, and stomach, as well as acute myeloid leukemia, are all evidenced in a greater percentage of smokers than of nonsmokers.
  • Smokers are two to four times more likely to develop coronary heart disease than nonsmokers.
  • Those who smoke have double the risk for stroke.
  • Smokers are 10 times more likely to develop peripheral vascular disease as well as abdominal aortic aneurysms than nonsmokers.
  • Ninety percent of all deaths from chronic obstructive pulmonary disease (COPD) are attributable to cigarette smoking.
  • Smokers are at increased risk for infertility, preterm delivery, stillbirths, delivering low birth weight babies, and giving birth to infants who later succumb to sudden infant death syndrome.
  • Postmenopausal women who smoke have lower bone density, which puts them at increased risk for hip fractures.

This is not a referendum for the abolition of smoking. Rather, discussions about smoking-related conditions that are ignited by a process-of-care measure for patients admitted with AMI, HF, and CAP have the potential to lead to enhanced patient care, better outcomes, a higher Hospital Compare score, and increased revenue. Money may be the catalyst for such discussions, but these discussions really do benefit everyone.

Substantiating Medical Necessity

It is critical in this process that any additional services truly be established as medically necessary, in that their purpose, first and foremost, should be to contribute meaningfully to the patient's ongoing health and well-being. To address this consideration, let's go back to our patient who was admitted for an AMI. As noted previously, the hospital care measure set recommends that patients identified as having a history of smoking should receive smoking cessation advice and counseling. When this information is entered into the EHR, the patient could also be flagged for a glucose tolerance test, because both myocardial infarctions and smoking are predisposing risk factors to diabetes mellitus.

Not only would an electronic trigger alert the physician that medical necessity has been established for the diabetes screening, it would also provide important information for the attending physician to consider in treating the patient. It is estimated that about 8 million people in the United States have diabetes and don't know it, and diabetes mellitus is a known contributing factor to about 50 percent of myocardial infarction cases.

Of course, routine testing of every patient for diabetes mellitus is unrealistic. Through the use of these triggers, medical necessity might be substantiated for a patient who might have poor glycemic control. Another bonus: This trigger would tie in directly with one of the hospital-acquired conditions on the inpatient prospective payment system (IPPS) list for 2009: manifestations of poor glycemic control.

When a patient and his or her attending physician are unaware that the patient has diabetes, there is greater risk the physician will make medical decisions that are contraindicated in a patient with diabetes. Ultimately, the patient's condition could be aggravated, potentially leading to a hospital-acquired condition that not only harms the patient but also costs the hospital revenue, as Medicare will not pay for treating the condition.

There are five conditions specifically identified on Medicare's 2009 hospital-acquired conditions  list, all related to insufficient glycemic control. When the admitting assessment can alert to factors substantiating a glucose test, any of these hospital-acquired conditions could be either averted or identified early enough in the admission to qualify for present-on-admission (POA) confirmation.

Each of the three diagnoses (AMI, HF, and CAP) provides a legitimate medical reason for performing a blood glucose test. The earlier in the admission that medical necessity can be established for a blood glucose test and the test can be performed, the more likely a prediabetic, diabetic, or secondary diabetic condition, if present, can be documented as POA. Early diagnosis also means the patient will receive appropriate treatment throughout his or her hospital stay, and it thus provides a strong foundation for an improved patient outcome.

Cost Implications

Screening for existing conditions also has a direct impact on the assignment of the DRG. Table five of the FY09 final rule (Federal Register, Aug. 19, 2008) identifies diabetes mellitus as a major complication or comorbidity (MCC). According to this table, last year's DRG numbers for AMI with and without an MCC show the extent that these screenings could increase an organization's revenue. As published in the IPPS final rule, these numbers, from FY07 data in the Medicare Provider Analysis and Review database, are $60,597.58 per stay for DRG 250-AMI with MCC (6,424 cases), as compared with $35,719.81 per stay for DRG 251-AMI without MCC (39,456 cases).

The discovery of an MCC such as diabetes mellitus not only improves patient care and patient outcomes, but also has the potential to add $24,877.77 per patient, per stay to the organization's Medicare reimbursement ($60,597.58 2 -$35,719.81 = $24,877.77).

Now, look at the numbers and weights for the MS-DRGs in the FY09 final rule. The new DRG 280-AMI, discharged alive, with an MCC- is reimbursed at a payment weighted at 1.9404, whereas DRG 282 AMI, discharged alive, with no MCC or CC, gets a payment weighted at 0.8696-less than half. These numbers seem to establish a foundation for this program to provide an excellent ROI for implementation.

Additional opportunities also exist. Consider a patient who is admitted with HF and a history of smoking. These two factors support screening this patient for coronary artery disease, stroke, and peripheral vascular disease. There also are structural or functional causes of HF including heart tumors and lung disease for which the patient can also be screened. There are several lung disease diagnoses shown on the MCC list for 2009.

A Swan-Ganz catheter, also known as a right heart catheterization, may be needed in some cases of HF. In such cases, extra precautions should be taken to prevent the patient from contracting a hospital-acquired infection. In FY07, Medicare processed 29,536 cases of vascular catheter-associated infection as a CC reported with code 999.31: infection due to central venous catheter. These claims averaged $103,027 per hospital stay. That's a lot of money to be tied to a hospital-acquired condition with "payment implications."
Now let's consider a female patient admitted for CAP who is also a smoker. If this CAP patient is postmenopausal, there is another potential health concern-osteoporosis. Therefore, when these elements-CAP, smoking, and postmenopausal-are entered into the record, this patient should be flagged for a bone density test that can identify the patient's potential increased risk of fracture.

When the screening can be performed early in the admission, the chart can be flagged and the clinical staff can be alerted to this patient's added susceptibility to fractures and implement additional strategies to prevent falls and traumas. In FY07, Medicare processed 193,566 cases for falls and trauma at an average of $33,894 per hospital stay. When occurring during the hospital stay, falls and trauma are hospital-acquired conditions with payment implications. A patient admitted for CAP, with a history of smoking, also supplies medical necessity for screening for COPD. A positive diagnosis for COPD is on the 2009 CC list and therefore may affect reimbursement.

Now, let's move on to another condition on CMS's 2009 list of hospital-acquired conditions: pressure ulcers (also known as decubitus ulcers
or bedsores). The 2009 ICD-9 chargemaster has new codes (707.21-707.25) for the staging of these ulcers, and they can be connected with more information to improve revenues. A stage II pressure ulcer that is POA and that develops into a stage III pressure ulcer during the hospital stay becomes a hospital-acquired condition with payment implications. It is important to educate the coding department to ensure the documentation from the history and physical is being interpreted correctly so that a patient with a pressure ulcer will be reported with the correct stage that is POA.

Next, physicians should be educated regarding their documentation of this condition. In reality, there is a big difference between stage II and stage III ulcers. Therefore, the clinical documentation must provide the necessary information to accurately stage the ulcer. Again, during the admission assessment, the EHR might flag factors that may increase the risk for pressure ulcers, such as a patient who has a chronic condition (e.g., diabetes or vascular disease, which prevents areas of the body from receiving proper blood flow; a mental disability from conditions such as Alzheimer's disease, because the patient may not be able to properly prevent or report pressure ulcers; older age; urinary or bowel incontinence). Is it worth the effort? In FY07, 257,412 cases were processed by Medicare at just over $43,000 each. This is a huge number of cases and certainly something that deserves additional attention. The new 2009 diagnosis codes for reporting a stage III or stage IV ulcer are considered MCC for 2009 and are on the 2009 list of hospital-acquired conditions, as well.

So if you can implement these extra triggers, starting with just these three admitting diagnoses, patient outcomes will improve, and the organization will receive a boost to its bottom line. Moreover, these steps will have impact for the balance of this year and through next year as well. Heart failure, pneumonia, and heart attack not only are included in the 42 measures for FY10, but also rank among the 10 most common diagnoses for Medicare inpatient care, and they therefore have the greatest potential impact on a hospital's revenue.

The Role of Finance

Senior financial managers can help to establish these internal processes by bringing together the clinical and IT departments so these triggers can be properly programmed into the EHR system. Participation and utilization can then be integrated into daily work habits more easily.

The possibilities for improved patient outcomes should help gain clinical staff buy-in, while the potential for improved patient care should gain the support of executives and board members. The ROI of programming time to input the triggers should quickly become evident because the training required is minimal. By building automatic triggers into your EHR that remind clinicians to refer patients for additional services when medical necessity has been established, both your patients and your organization will reap the rewards.

Shelley C. Safian, MAOM/HSM, is associate professor, Berkeley College, Longwood, Fla. (

Publication Date: Tuesday, September 01, 2009

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