DRIP Systems vs Information Systems
by Stefani Daniels, RN, MSNA, CMAC, ACM
Published on May 29, 2015
No matter what information system your hospital uses, it produces data.....lots of data.....more data than you can possibly imagine....and more data than you can probably use. There's only one snag: Hospitals are still having a hard time converting the data into information. We call these facilities DRIP organizations: Data rich, information poor. Without information, hospital executives, department leaders, physicians, and case managers are operating blind.
At a recent visit to a 260-bed hospital in North Carolina, we were informed about the high payer denial rate. The CEO stated that denial prevention was one of the goals he set for a new, more contemporary care management program. In the greater scheme of an outcome case management model, this is a frequent and not unusual goal. To create a baseline, we asked for a report of all the denials that occurred in the last fiscal year. We were given a report purporting to be denials but the amount seemed to be usually high. When we sat down with their financial analyst and did an intensive analysis, we discovered that the report was actually data on all contractual write-offs as well as the denials. There wasn’t a distinct report reporting payer denials! In other words, the CEO based his concern about denials on a report that aggregated all write-offs: contractual write-offs, expenses that would not be paid for based on the payment model that the hospital agreed to in their contract with the payer; and denials, expenses that would not be reimbursed due to lack of medical necessity documentation. Information on denials simply didn't exist. We could not identify the amount of the denials, the reasons for the denials, nor the payers who were issuing denials. Without that information, we explained, the case managers were at a tremendous disadvantage. Without monitoring denials, the neither the case managers nor utilization reviewers could be accountable for managing them. After a lengthy discussion with the CEO and CFO on how denial information is the basic building block for clinical denial prevention, the CFO began to explore ways to report the information.
Another example we recently encountered involved staffing allocation. As you may know, we use of total patient days to estimate case manager personnel needs. We were given three different reports listing FY 11 patient days and all three had different totals. Two of the reports showed totals that were in the same 'ball park' but the third report had a total that was a considerable deviation for the same time period. What were we to believe? When we encounter these kind of discrepancies, we become very suspicious of all other data received.
Despite sophisticated information systems and the growth of electronic medical records, we remain amazed at the lackadaisical approach to information analytics. That data-to-information conversion challenges still exist in hospitals, given public reporting, transparency, pay for performance, and quality/safety initiatives, is mind-boggling.