Healthcare News & Insights

Adherence to evidence-based standards creates quality and financial alignment for hospitals

There are two sides to every hospital – the clinical side and the financial side. Meshing the two together isn’t easy since they both have different focuses. In this guest post, Howard Willson, MD, MBA, SVP of customer success at a provider of evidence-based clinical decision support systems through electronic health record systems, will explain how the two sides can find common ground through evidence-based practices.

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A tension often exists between hospitals’ clinical and financial teams, with each side intently focused on its own work to the detriment of the other.

However, a shared commitment to following evidence-based standards can create alignment among clinical and financial teams by unifying all stakeholders around a vision of doing what’s right for the patient. Then, by focusing on providing high-quality, evidence-based care that avoids both under- and over-utilization, financial success can follow.

To some extent, it’s understandable that clinical and financial teams aren’t always aligned. On a day-to-day basis, clinical teams are most focused on providing patients with high-quality care, while financial teams are often occupied with ensuring an accurate charge description master (CDM) and charge capture.

The language that these two groups employ to communicate with each other also may stand in stark contrast. A significant portion of medical terminology is based on a complex, multisyllabic vocabulary with origins in Latin. Providers and clinical staff communicate in the words of patient care – tests, procedures, medications, conditions, etc.

Alternatively, revenue integrity teams speak in the language of code sets for charging and billing. Financial employees are tasked with translating the language of patient care into codes used in the CDM and for charge capture.

Despite these differences, the gap between the two teams can be closed in a way that improves quality and ensures accurate charge capture. It starts by implementing technologies that unite clinical and financial teams around the same goals and language. Next, hospital leaders can leverage tools that analyze whether providers are following evidence-based standards for various conditions, and whether the hospital is appropriately billing for the services it has rendered.

Common ground through evidence-based practices

For most health systems, one of the biggest challenges around technology is selecting the right systems to overcome the clinical-financial gap. To create a bridge between the two, hospitals should combine clinical software (such as electronic health record systems and decision support tools) with financial systems (such as accounts receivable and data analytics).

By connecting disparate systems, leaders can identify what therapies their providers have ordered and link those therapies with individual patient charges and billing codes. They can also determine whether or not the CDM and patient claims accurately reflect the care delivered, and identify additional charge-capture opportunities.

Evidence-based practices play an important role in this process. Centering both clinical and financial operations on evidence-based guidelines helps teams overcome their traditional divide as they unify around the same goal. Providers and clinical staff will strive to follow evidence-based practices, which offer the best opportunity for high-quality outcomes.  Financial teams will advocate for evidence-based practices because following these guidelines can lead to higher revenues under value-based agreements that reward providers for quality performance.

From a philosophical standpoint, hospital leaders want to provide the appropriate interventions for patients. One problem many leaders face, though, is that, from a quality perspective, they cannot confirm if clinicians are following evidence-based practices and if the associated therapies are under- or over-utilized. Further, from a financial perspective, leaders often aren’t aware when the organization may be leaving money on the table as a result of clinicians’ non-adherence to evidence-based practices.

However, with a solution that compares a hospital’s actual interventions and associated billing with evidence-based guidelines, leadership can optimize both care quality and the organization’s financial stability.

Charging and coding accuracy supports financial sustainability

As more hospitals struggle to maintain financial viability, proper charging and coding has become increasingly important for long-term survival. The rise of hospital closures and bankruptcies, particularly in rural areas, is problematic for the communities left without ready-access to medical care. In the event of a traumatic accident, for example, the difference between traveling 10 minutes and 90 minutes for medical treatment could be the difference between life and death. Care that adheres to evidence-based standards – coupled with accurate coding, charging and billing – contributes to the financial sustainability of hospitals.

For a number of health systems, better compliance with evidence-based guidelines – and ensuring appropriate billing practices – may improve care quality, as well as yield a significant return on investment. For example, by ensuring all patients with diabetes receive annual foot exams, a hospital adheres to evidence-based standards for high-quality care and achieves a key quality measure that may yield incentive payments under value-based contracting arrangements.

Standardization bridges the divide

For clinical and financial teams, standardizing practices around evidence-based guidelines promotes collaboration around mutual objectives. Focusing operations on evidence-based practices enables each team to speak the same language, helps everyone achieve individual team goals, and paves the way for the hospital to meet two of its top organizational goals: Improving patient care and ensuring the organization’s ongoing financial viability.

We must remember that everything begins with doing right by the patient. When clinical teams provide care that follows the appropriate evidence-based guidelines, and financial teams align billing practices with care, hospitals are well-positioned to achieve their goals.

Howard Willson, MD, MBA, is SVP of customer success at Zynx Health, a provider of evidence-based clinical decision support system solutions made available at the point of patient care through electronic health record systems.

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