At HFMA Revenue Cycle in Dallas, Texas (Mar. 18–20), Shameka Hooks, Executive Director of Midcycle Operations at WakeMed Health and Hospitals, shared how WakeMed shifted from chasing documentation after the fact to capturing it during the encounter — and what that change produced clinically and financially.
Key takeaways
- A documentation problem is a diagnosis problem. Physicians can only review up to 3% of chart data. The other 97% goes unseen, along with the diagnoses and revenue it holds.
- Point-of-care documentation is the only kind payers can’t deny. Retrospective queries are increasingly losing the fight. The window to defend a diagnosis is during the encounter, not after discharge.
- Physician ownership determines whether any of this sticks. Physicians who choose a tool are fundamentally different from physicians who have one handed to them.
Your documentation problem is a diagnosis problem
WakeMed is one of the ten busiest EDs in the country: three hospitals, nearly 1,000 beds, more than 1,200 providers. When Hooks and her team looked at what was driving incomplete documentation and growing denials, the issue wasn’t effort. Clinicians were doing everything they could with what they could see.
The problem was how little they could see. With only 3% of chart data reviewed in a typical encounter, diagnoses go missing not because physicians aren’t looking, but because the chart is too large and the day too short. A chronic condition documented on day three of a twelve-day stay can drop out of view by day ten. It doesn’t get carried forward. It doesn’t make it into the note. And by the time a CDI specialist sends a query after discharge, it may already be too late to defend.
49% of physicians in a Medscape survey reported burnout, and 20% reported depression. The EHR was among the most commonly cited contributors. Clinicians were managing alerts, messages, and documentation demands that displaced time with patients rather than supporting the care they were delivering.
Retrospective queries are losing ground
Payers are paying close attention to when documentation happens. Diagnoses captured at the point of care, backed by clinical evidence in the record, hold up. Diagnoses added through retrospective queries increasingly don’t, and the pressure is growing.
That changes the math for CDI. Retrospective queries recover a fraction of missed revenue, and that fraction is shrinking. Getting ahead of this means solving the problem during the encounter, before any query is necessary.
This was the case Hooks made to WakeMed’s executive leadership. Not just that documentation was incomplete, but that the gap between care delivered and care captured was costing the system money it had already earned, and that the only durable fix was upstream.
Care captured, revenue earned
Eight months in, WakeMed had prevented $9.3 million in denials and generated $871,000 in MS-DRG upgrades. Documentation accuracy scores climbed at every campus, with the system-wide score moving from 68% to 78%. CC and MCC capture rose across high-value diagnoses, and mortality outcomes improved across AMI, pneumonia, severe sepsis, and stroke.
Hooks was deliberate about presenting results in terms physicians care about alongside the financials. Quality scores and outcomes move clinicians in ways that reimbursement tables don’t. CDI query agreement rates climbed from 80% to 88% as physicians came to see the revenue cycle team as helping them get credit for care already delivered, rather than adding work after the fact.
WakeMed started with hospitalists, added a physician advisor program, and has since expanded into cardiology, surgery, pediatrics, and orthopedics. The principle that guided it: focus on what matters to the clinician in front of you, and the financial results follow.
