Johns Hopkins Medicine, headquartered in Baltimore, Maryland, is an $8.5 billion integrated global health enterprise and one of the leading health care systems in the United States.
Like many hospitals and health systems, Johns Hopkins asked its physicians to participate in a time-consuming, burdensome documentation task - the physician query process. The multistep, cumbersome query process for Johns Hopkins physicians included: fielding emails, phone calls and texts, logging into the EMR, searching for the query within the in basket, finding the patient's chart, creating an addendum to the record, and responding back to the clinical documentation specialist or coder – all of this taking 15 to 20 minutes to address a single query. Consequently, physicians were responding to anywhere between 50% to 84% of queries, depending on the hospital.
Physician responses to documentation queries are important. They ensure hospitals and physicians receive proper reimbursement for services and report quality measures accurately. In general, unanswered queries lead to claims that cannot be processed, bad debt and inaccurate quality measures.
At the time, Johns Hopkins physicians were not the only ones dissatisfied with the query process. Clinical documentation improvement (CDI) specialists and coding staff were overwhelmed by the significant time and effort required to manually track and follow-up on unanswered queries. One CDI specialist commented, "Typical physician response times are anywhere from weeks to never."
Adding to these challenges, Johns Hopkins operates under Maryland's unique All-Payer Model and must accurately capture performance measures to participate in the Centers for Medicare & Medicaid Services' (CMS) Total Cost of Care (TCOC) Model. Under Maryland's payment model, capturing accurate clinical documentation for coding episodes of care is critical to maintaining CMS quality measure targets.
Johns Hopkins Medicine needed an innovative physician query solution that would solve multiple problems:
- Increase physician engagement and accountability
- Standardize and automate the process for CDI and coding staff
- Remove the unnecessary burden on physicians
"Under Maryland's unique all-payer system, we thoroughly understand the importance of strong physician engagement in CDI programs to support quality-based reimbursement models. We welcome opportunities to enhance our efficiencies in ways that are convenient to physicians."
– Peter Greene, M.D., Chief Medical Information Officer for Johns Hopkins Medicine
In 2016, the Johns Hopkins Technology Innovation Center (TIC) collaborated with startup, Artifact Health, to bring to market a cloud-based, HIPAA-compliant, mobile physician query platform. The Artifact platform would give Johns Hopkins physicians an easier and faster way to respond to queries about their documentation allowing the health system to add greater specificity to patient records and improve coding accuracy.
Artifact Health and the TIC conducted a successful pilot at Johns Hopkins Howard County General Hospital in Columbia, Maryland with the guidance and support of physicians and the hospital's CDI and coding staff. The physicians' enthusiasm for the tool, along with an immediate increase in response rate, decrease in response time, and enhanced CDI productivity, were primary factors in the decision to deploy the technology across the enterprise.
By spring of 2017, Johns Hopkins launched Artifact across its five hospitals in the Baltimore/D.C. region as a give-back to physicians under the "Joy of Medicine" program, an initiative to promote physician wellness by helping providers rediscover the joy that comes from caring for patients by removing unnecessary administrative burdens.
As part of the Joy of Medicine program, Johns Hopkins physicians insisted on a reduction in notifications received in the in basket. They considered the overwhelming number of items in the in basket a contributor to physician burnout. Other physicians began reporting the same, as described in this article published in November 2018 by Dr. Atul Gawande.
After deploying Artifact, Johns Hopkins query response rate increased immediately and has remained between 95-100 percent for the last four years. The increase in physician engagement around queries resulted in higher-quality documentation and more accurate publicly reported quality outcomes.
The most striking result was the immediate improvement in provider satisfaction around query workflow. A physician leader remarked, "Getting a true baseline measure of physician satisfaction is difficult, but I can tell you the difference [with Artifact] is palpable. It's the only technology I can recall adopted voluntarily by Hopkins physicians because they liked it."
For that reason, average physician response times for both concurrent and retrospective queries dropped to 48 hours or less, with many providers responding within 1 hour of receiving the query in Artifact. This is compared to a 14-day average response time recorded previously.
"It's very easy to use and providers love it. Many wanting to be the provider with the quickest response rate!"
– Johns Hopkins CDI leadership
In addition, CDI leadership reported a significant increase in query rate. CDI specialists gained more time to review charts because they no longer had to track down physicians with unanswered queries. The efficiencies gained resulted in increased query volume.
Coding staff became more confident that queries would be answered quickly. Consequently, the number of retrospective queries increased as well. The faster response times reduced accounts receivable days and DNFB dollars by 65% at The Johns Hopkins Hospital when Artifact went live.
Reported for 2018, Artifact helped Johns Hopkins Medicine realize over $6.6 million in increased revenue due to the ability to obtain timely and accurate responses to queries related to potentially preventable complications.
By early 2019, Johns Hopkins expanded Artifact to streamline documentation clarifications across two new areas – professional fee billing and outpatient physician practices. The decision to expand to professional fee billing was driven by physician demand. Physicians requested all documentation clarifications be delivered via Artifact.
Johns Hopkins created the first pro-fee query template library within Artifact to facilitate queries across twelve departments. As seen in the inpatient environment, response rates to pro-fee queries increased and response times dropped significantly. Previously, charges were not finalized until providers created an addendum to the note in the EMR and emailed the coder that it was done, often taking weeks to complete.
Artifact was also deployed to manage queries for Johns Hopkins Community Physicians (JHCP), including over 40 primary and specialty care outpatient sites and over 1,000 providers. To succeed in risk-based population health models, provider organizations must ensure that physicians capture specific disease categories for optimal quality reporting and reimbursement. JHCP implemented Artifact to help with the accurate coding of Medicare Advantage patient care under the Hierarchical Condition Category (HCC) payment model.
With Artifact handling query workflow for all types of documentation clarification requests, Johns Hopkins has tackled other initiatives to improve the quality of clinical documentation. For example, Johns Hopkins leveraged Artifact Health's relationship with HCPro/ACDIS, to adopt the ACDIS compliant query template library. The ACDIS template library helps ensure consistent and compliant query formats, reduce decision fatigue for providers, and provide query guidance for CDI and coding staff.
In October of 2020, Johns Hopkins added Artifact to their children's hospital, Johns Hopkins All Children's Hospital in St. Petersburg, Florida, with a new library of pediatric query templates.