Optimizing Neurology Inpatient Documentation: A Pilot Study of a Novel Discharge Documentation EHR Tool.

Background and Purpose: Clinical documentation of patient acuity is a major determinant of payer reimbursement. This project aimed to improve case mix index (CMI) by incorporating a novel electronic health record (EHR) discharge documentation tool into the inpatient general neurology service at the University of California, Los Angeles (UCLA) Medical Center. Methods: We used data from Vizient AMC Hospital: Risk Model Summary for Clinical Data Base (CBD) 2017 to create a discharge diagnosis documentation tool consisting of dropdown menus to better capture relevant secondary diagnoses and comorbidities. After implementation of this tool, we compared pre- (July 2017-June 2019) and post-intervention (July 2019-June 2021) time periods on mean expected length of stay (LOS) and mean CMI with two sample T-tests and the percentage of encounters classified as having Major Complications/Comorbidities (MCC), with Complication/Comorbidity (CC), and without CC/MCC with tests of proportions. Results: Mean CMI increased significantly from 1.2 pre-intervention to 1.4 post-intervention implementation (P < .01). There was a pattern of increased MCC percentages for "Bacterial infections," "Other Disorders of Nervous System", "Multiple Sclerosis," and "Nervous System Neoplasms" diagnosis related groups post-intervention. Conclusions: This pilot study describes the creation of an innovative EHR discharge diagnosis documentation tool in collaboration with neurology healthcare providers, the clinical documentation improvement team, and neuro-informaticists. This novel discharge diagnosis documentation tool demonstrates promise in increasing CMI, shifting diagnosis related groups to a greater proportion of those with MCC, and improving the quality of clinical documentation.

Fast Neuro: A Care Model to Expedite Access to Neurology Clinic.

Background and Objectives: We set out to improve outpatient neurology access while reducing patient volume in the emergency department (ED) for nonemergent neurologic complaints. Methods: We created a rapid access model, University of California Los Angeles (UCLA) Fast Neuro, for patients referred from affiliated EDs to outpatient neurology, enabling appointments within 1 week of referral. Rapid access appointments were also available to established neurology patients with urgent concerns. Fast Neuro was built to reduce nonemergent neurologic care in the ED, improve outpatient neurology access, and avoid use of inpatient neurology services for nonemergent consults. The volume of referrals and neurology consults from the ED and wait time from referral to appointment were measured. Surveys were conducted at 3 and 6 months to assess satisfaction with the model by all stakeholders. Results: From January 2019 through January 2021, 201 patients were referred to outpatient neurology through UCLA Fast Neuro. Wait time for an outpatient neurology appointment was reduced from the prior period by 82.5% (7.0 ± 5.5 vs 40 ± 4.1 days). The number of nonemergent consults from the ED was reduced by 60% (4.1 ± 1.9/mo vs 10.3 ± 1.7/mo). Surveys showed wide acceptance of the new model with 92% of attending physicians and advanced practice providers and 89% of residents endorsing that UCLA Fast Neuro patients did not detract from their clinic experience. Discussion: UCLA Fast Neuro improved ED throughput, reduced inpatient neurology consults from the ED, and decreased wait times for outpatient neurology appointments without using the inpatient neurology service for nonurgent consults. UCLA Fast Neuro was successful. Exploration of how to scale and implement the model of access more broadly is warranted.

Implementation and Evaluation of a Neurology Telemedicine Initiative at a Major Academic Medical Center.

Introduction: The COVID-19 pandemic forced rapid adoption of telemedicine for care of neurology patients. This study contributes to this literature by describing the structure and implementation of telemedicine-based outpatient neurology clinics at the UCLA Medical Center and estimates patient cost savings, before and after the California COVID-19 "Safer at Home" directive, and patient satisfaction. Methods: This was a retrospective, nonrandomized, case series study of telemedicine-based neurological management in an urban academic medical center from October 2018 to June 2020. We estimated roundtrip travel time, roundtrip travel distance, total savings, and surveyed patient and provider satisfaction with telemedicine care. We supported these findings through evaluation of 7,194 patients by telemedicine and conducted 9,189 video visits for neurological care. Results: The median telemedicine patient avoided a roundtrip driving distance of 33 miles and roundtrip travel time of 75 min. Within sample, median hourly earnings were $27/h. The median patient saved $18 on fuel and parking and $36 of time-based opportunity savings, for total savings of $54 per video visit. Eighty-six percent of patients surveyed were satisfied with their video visit experience. Conclusions: Telemedicine reduced travel time and also reduced costs for neurology patients. Patients and providers both reported high levels of satisfaction with telemedicine.

Prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program.

Existing literature suggests that use of telemedicine during postoperative appointments can increase access to care and is valued by patients and providers alike. While research examining the clinical equivalency of telemedicine visits for postoperative care has been growing, few studies have reported on telemedicine follow-up after neurosurgery. This study examined if a videoconferencing visit could substitute for an in-person clinic visit for elective neurosurgical cases in the USA. This was a single-center prospective study of patients who underwent elective neurosurgical procedures (aneurysm clipping, resection of cavernous angiomas, resection of arterial venous malformation, microvascular decompression for trigeminal neuralgia and hemifacial spasm, and certain benign brain tumors) and were offered telemedicine follow-up care by an allied health professional during the first 90 days after neurosurgery. Prospective data was compared to a historical group of patients who underwent the same procedures and received in-person postoperative follow-up. Patients in the prospective group were contacted by telephone 2-6 weeks after surgery by a nurse practitioner and assessed using a standard template that included incidence of reported postoperative seizures, fever, and performance of activities of daily living. Primary outcome measures included percentage of patients accepting telemedicine, clinical and functional status, complications, patient satisfaction, patient travel time and distance, and rates of emergency room care or hospitalization within 90 days of discharge. Ninety-nine patients were included in the study, with 57 in the prospective group and 42 in the historical group. Of the 57 prospective patients, 47 accepted telemedicine in lieu of an in-person clinic visit. Emergency room visits and readmission rates at 30 and 90 days postoperatively did not differ significantly between the study groups, nor was there any significant difference in clinical variables that were recorded in the electronic medical record more than 80% of the time. This study demonstrates the safety and value of telemedicine as an alternative method of postoperative clinical care for patients undergoing elective neurosurgery. Telemedicine avoids unnecessary travel time and was welcomed by the majority of patients without compromising clinical or functional outcomes.