A Health & Wellness Plan for Managing YOUR Wound Clinic

It is possible for hospitals and wound care providers to manage their own clinics without external oversight. Here’s how to do so appropriately, safely, and successfully.

Wound care clinicians strive to find the best methods to manage their patients just as hospitals strive to find the best way to manage patient programs. Wound clinic hospital-based outpatient departments are particularly challenging programs to manage due to both the nature of complicated billing codes that necessitate specific types of documentation to ensure proper payment and required advanced therapeutics — the use of which are governed by detailed local coverage determination (LCD) regulations. If hyperbaric oxygen therapy (HBOT) is offered in the clinic, there are additional daunting safety requirements to be met to ensure the safe operation of this highly specialized equipment. Additionally, healthcare reimbursement is driving us away from a “silo” approach to wound care delivery into one that facilitates wound care across the continuum. Regardless of the management model being employed, the maintenance and operating of any wound clinic cannot be achieved without dedicated providers who are equipped with and appropriately utilize the right “tools.” This article will discuss the option of operating a wound center “on your own.” We will consider benchmarking data from more than 100 facilities and how hospitals can use their “tools” to assess the overall health of one’s wound clinic. For the purpose of this article we will focus on a very narrow part of the new paradigm — specifically, how we gather healthcare information and interact with the patient during the patient encounter.

Assessing One's Wound Care “Toolshed”

Most of us have had the experience of needing to do some home-improvement projects on our own and are handy enough with a hammer, a screwdriver, or a power drill to not need to call a repairman for every little modification we desire. Does this mean we would also try to add another room to our homes? Not likely. Even those who could realistically handle a major renovation project might still decide to hire a contractor to do the work simply because their time would be much better managed differently. Hospital administrators who are interested in running their outpatient wound centers must perform a “skills assessment” before opening the doors and continue to self-assess on a regular basis in order to understand the capabilities of their facilities and their clinical staff members. Questions that must always be asked include, “Is wound care something we can perform ourselves? Is it something we should perform ourselves? Are there physicians, nurses, and therapists available who possess the necessary expertise? Are there successful wound centers in our own hospital system that might provide advice? Are there administrators at the hospital who have opened wound center programs previously?” In other words, it must be ascertained whether or not there are any tools already in the workshop and any skilled craftsmen already on the payroll. Then there’s the added need to go about deciding on the level of expertise required to manage the wound center versus how much need there is to rely on outside oversight.

Diagnostic Approach to Wound Clinic “Health”

It’s certainly possible for hospitals to manage their own wound centers without the use of a management partner. However, this is only possible if the hospital and its staff collectively has the appropriate tools as well as the clinical skills and level of expertise to use the tools correctly. This is a tall order, and the commitment required is often lacking within the hospital administrative structure unless the hospital is “forced” to do so within the terms of a management contract. In other words, it is often the financial pain of a management contract that gets hospital administrators to act in ways that are in their own best interest. Sadly, many program directors lack the influence at the administrative level to make needed changes to optimize their programs for success. To avoid the problem of “a prophet in his own town” being ignored, it is possible to use national benchmarking data to develop a picture of what a “healthy” and an “unhealthy” wound center program looks like. Interestingly, an unhealthy wound center program also tends to have fewer successful patient outcomes.

Detailed data from a purpose-built, wound care-specific electronic health record (EHR) were exhaustively analyzed from more than 100 wound centers in 32 states in a study conducted by this author. Data on billing patterns, clinic staffing, charting completeness, relative value units (RVUs), payer mix, workflow, patient-visit frequency, and the distribution of inpatient and outpatient mix were evaluated. Four things were found that determined the health of a wound center program: 1) patient volume, 2) operational efficiency, 3) revenue cycle management, and 4) regulatory compliance. To obtain advanced diagnostic information like this from a wound center, in-depth, highly granular information on physician and staff behavior, including the billing data from both the physician and the facility, was needed. In other words, an accurate diagnosis requires an accurate diagnostic tool. In this case, it was a purpose-built EHR through which both the advanced provider (AP) and the nurse remained committed to point-of-care (POC) charting that minimized the use of free-text typing and maximized the use of menu-driven structured language. The EHR internally audits the chart, calculating both the physician and the facility level of service based on the documentation present in the EHR so that both parties know what level of service can be substantiated in case of an audit. However, ensuring revenue integrity takes more than that. LCDs for advanced therapeutics such as cellular and tissue-based products can require the specific documentation of more than 20 different elements (eg, that vascular screening showed adequate arterial supply, that no necrotic material is present, that no deep structures are exposed, etc.). An EHR with sufficient granularity can run “edit checks” for each of these elements. The same is true as facilities begin the laborious process of HBOT pre-authorization. The requirements for HBOT preauthorization of a diabetic foot ulcer (DFU), such as vascular screening, offloading, hemoglobin A1c measurement, and infection management, can all be internally audited by an EHR that collects data in structured language (no free-text typing for these elements) and can run real-time programmatic queries to ensure the requirements of the LCD have not been breached. However, POC charting by the AP and the nurse using a purpose-built EHR with the proper capabilities is mandatory.

A Wellness Checkup

Let’s discuss a few details of this wound clinic health and wellness checkup based on benchmarking data from the US Wound Registry — a nonprofit corporation that seeks to create and operate data registries of patient volume, chronic diseases, medical products, and devices — starting with patient volume. As a general overview, a wound clinic that doesn’t see at least 40 new patients per month is “not profitable.” Zip code analysis should show that your catchment area extends outside your immediate zip code. The most successful clinics average 9.5 visits per patient and, while the interval between patient visits changes over the course of care, it should fall somewhere between 7-14 days. With regard to operational efficiency, the clinic has to be committed to POC electronic charting for both the AP and the nurse. However, there should be no “double entry.” Other than perhaps jotting down vital signs or wound measurements on paper due to infection control concerns, there should be no reason to keep both a paper chart and an electronic chart.

If you typically employ a double-entry method of charting in your clinic whereby staff members must document twice (once on paper and then later in the EHR), or there are multiple documentation systems (eg, physicians use one system and nurses use another), there is something terribly wrong with your EHR and your documentation processes.

Physicians should also not be dictating notes in another system because that means there’s a problem with how the medical record has been defined and how the capturing of data needed to establish medical necessity is being conducted. There shouldn’t be more than one medical record system per wound clinic. Charting should be aligned with what is needed to ensure payment for services. Under-charting means loss of revenue, but over-charting of data that are not important is a waste of staff resources.

The management of the revenue cycle could fill an entire book. Many excellent articles have been written to explain why daily (not monthly or serial) billing is mandatory to ensure proper charge capture for HOPDs. Nevertheless, many hospitals are still not willing to make the changes necessary to perform daily billing. Hospitals often do not track partial payments received as a result of serial billing, and thus large sums of money are unable to be collected when applying for inpatient billing practices to outpatient departments. In many cases, hospital administrators will not even provide wound center program directors or clinic managers with access to vital reimbursement information. Management companies may be successful partners for wound clinics in part because the contracting process can be utilized to enforce access to reimbursement information. It remains a mystery to this author that hospital administrators would not wish to empower their own managers to monitor this information.

Benchmarking data makes it possible to assess the percentage of revenue the average wound clinic should realize from compression bandaging, cellular product application, debridement, total contact casting, and changing negative pressure wound therapy (NPWT) dressings in relation to patient volume. For example, the average wound clinic should realize about 8% of its revenue from NPWT dressing changes. While a wound clinic may have a unique patient population issue (eg, a particular focus on DFUs rather than venous ulcers), there are general metrics that hold true from one facility to another. If a clinic’s procedural metrics are significantly out of alignment with the national benchmark, the providers are not performing some procedures they should be performing or the clinic is not billing for all the procedures being performed.

It is imperative that clinic administration evaluates staffing in light of procedural and volume numbers. What is a wound clinic paying for the staff it employs to perform provided services? If the benchmark clinic shows that two nurse full-time equivalents (FTEs) can handle 40 patients per month, why would one clinic require, say, four nurse FTEs to see 30 patients per month? In other words, staff productivity can be based on patient acuity as well as RVUs to get a clear picture of whether the ratio of staff to volume is appropriate. The argument is often made by staff members that “their patients are very sick.” However, the granularity of the data within can provide a window into which we have access that tells us not only the average acuity of the patients in the entire clinic but the average acuity score of the patients seen by a given staff member. Thus, it is possible to determine which nurses either see the most complex patients or do the most thorough job of documenting the patients seen. That means it is possible to understand the amount of revenue that a specific staff member is responsible for generating — or for losing. It is also clear there are outpatient clinics doing a great deal of inpatient work. As the outpatient payment models continue to breakdown “silos” of care, this trend may continue. However, it is important for hospital administrators to understand the revenue impact of having outpatient nurses providing inpatient wound care.

The risk of revenue loss is the final area that determines wound clinic health and wellness. Clinics that are not committed to POC charting are far less likely to have acute and complete charting, and thus records that can withstand an audit. Clinicians who make extensive use of free-text typing are more at risk than those who make use of menus that are specifically designed to meet the documentation requirements of LCDs. A significant area of exposure occurs in those clinics that allow more than one clinician to chart at the same time. There are only two ways this is possible. The first is to have the “nursing documentation area” of the chart divorced from the physician chart, whereby nurses can document and signoff on their portion of the chart without the physician seeing their notes. This is a problem for the Hospital Outpatient Prospective Payment System environment in which the nurses are providing services “incident to” the physician. More importantly, it means the physician (or AP) is making his or her notes regarding the need for debridement or other interventions separate from the nursing document, which might or might not substantiate what the AP has written — a situation that is a recipe for monetary recoupment if their notes do not agree (eg, the nurse documents the wound is “granulated” and the physician documents the wound has “necrotic material” and then performs a debridement). For half a century, the outpatient visit (either in a doctor’s office or in a clinic) has involved a relatively brief interaction with an AP who might scribble a few notes during the encounter and then conduct “the real charting” at a place and time distant from the patient encounter. The national initiative to adopt EHRs has been predicated on the idea that the AP and the nurse will perform POC charting (in the room with the patient). This is imperative in order to enjoy all the dividends that an EHR can provide, such as drug-to-drug interaction warnings within electronic prescribing (even warning patients that a medication is not covered by an insurance plan), and, most importantly, clinic decision support, which helps practitioners provide evidence-based care. These reminders may be as rudimentary as “provide adequate compression,” but they can also provide a risk assessment of the patient’s likelihood of healing in order to direct patients into pathways of care. APs can no longer scurry off to a dictation closet to perform charting. There must be interaction with a wound care-specific EHR while both the AP and the nurse are with the patient. The optimal financial and clinical outcome of the wound clinic depends on the adoption of POC charting. The other way in which more than one person can chart at the same time is actually to give the perception that this is occurring when, in fact, it is not. What is happening here is that the last person to chart is (potentially) overriding the notes made by the previous individual. This is the last-one-in-wins method of charting in which dual entry is really an illusion. The reason this is a regulatory compliance nightmare should be obvious. Keep in mind there are now eight regulatory bodies that perform compliance auditing and many of them use analytical tools to look for statistical anomalies in billing. The best defense against an audit is to be performing some of those same billing analytics internally, which means having an EHR capable of performing these functions.

Your Hospital EHR Isn’t Enough

The analytics mentioned here can’t be completed within a hospital’s EHR because they are designed to optimize the capture of data for the billing of inpatient services. When it comes to outpatient services, these EHRs are round pegs trying to be placed in square holes. Hospitals across the country have press-ganged wound care clinicians into writing “templates” for various outpatient wound care services, but these EHR templates will never be able to collect data in a sufficiently structured way to ensure accurate and LCD-compliant billing of complex outpatient services such as cellular products or debridements. Nor will they calculate the use of facility staff resources or wound clinic patient-acuity level, track dressing product use or costs, archive photos, track data on referring physicians or ancillary revenue, or automate correspondence with referring physicians — an activity that is vital for clinical quality as well as for marketing. Most importantly, hospital EHRs are designed to capture data for only a few general Physician Quality Reporting System (PQRS) measures. (Any clinician who has tried to get a major hospital EHR vendor to make a small EHR modification knows how frustrating it is to get help with even small programming changes to facilitate data collection.) The future of outpatient wound care reimbursement will hinge on the ability of an EHR to report wound care-specific quality measures through a qualified clinical data registry (QCDR). This will require considerable cooperation and dedicated resources on the part of the hospital EHR vendor. As the director of a QCDR, this author knows that hospital EHR vendors to date have not been willing to facilitate the reporting of QCDR measures, even when the measures are provided as electronic clinical quality measures that are ready for installation. A hospital administrator would not require a surgeon to use the wrong instrument in the operating room if doing so would cause the procedure to fail. Hospital administrators must understand the future of their wound care outpatient programs is directly linked to the proper use of the right tools — ie, a wound care-specific EHR capable of collecting and transmitting the necessary data for the financial success of this outpatient service. There is another reason a wound care specific EHR is vital, and that is the advent of ICD-10-CM.

The ICD-10 Elephant In The Room

ICD-10 could have a substantial impact on the way wound clinics operate. Historically, wound clinic billing has relied on the idea that the AP will use certain important “terms” that will drive hospital coders to select the correct ICD-9 code from a relatively narrow list of codes. The challenge with ICD-10 is two-fold: First, there is an enormous increase in codes, making it more challenging to find the code that best describes the condition. Second, the payers have been challenged to determine which of these thousands of codes most accurately reflect the conditions they have previously covered for a specific service. There is a way for a purpose-built EHR for wound care using structured language to simplify the process of code selection, but it requires elegant programming and a clear understanding of coverage policy. That won’t happen with a generic hospital EHR. 

Hospital administrators may believe that outsourcing the management of their wound clinics will solve the many significant challenges encountered in running the program. However, if the management company is not using adequate and current data collection methods, if the providers in the clinic are not committed to capturing the necessary data and doing so at the POC, and/or if the proper analytical tools are not in use, then outsourcing the management of the clinic will not ensure success. For example, there are management companies not using EHRs certified for Stage II Meaningful Use, have no plans to transition from volume- to value-based revenue, do not support quality reporting, and/or do not facilitate the selection of the proper ICD-10 codes within the EHR to ensure reimbursement for critical wound care services. Without critically necessary tools in place by the management company, hospitals may risk between $300,000 and $4 million per year in management services that cannot possibly ensure successful programs. On the other hand, if the proper tools are in place but administrators do not have the skills and knowledge to use them, the “do it yourself” model will be a colossal (and equally expensive) failure. Successfully managing a wound center, like successfully managing a patient, requires the proper tools in the experienced expert’s hands.

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of US Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.