Building a scalable documentation structure

Background

When UpLift launched, therapists had two options for submitting sessions: They could either store progress notes on platform using a free text field or they could check a box to attest that they were storing their notes elsewhere.

These notes track progress, demonstrate medical necessity, protect the provider from liability, and make insurance reimbursement possible. In other words, progress notes are one of the most vital parts of the patient record….they are also one of the most dreaded. When researching clinical notes, I found an article titled “I’d rather clean the toilet than write progress notes.”

To have a complete patient record, UpLift needed to change their approach to documentation—ideally with a solution that therapists enjoyed more than cleaning their bathrooms.

What wasn’t working…

Absent a clear framework, providers tend to procrastinate completing progress notes. Delayed documentation compromises clinical integrity. Not to mention, UpLift cannot submit insurance claims until the therapist submits a note or attests they have stored the note on the other platform.
Delivering quality care is core to UpLift’s value. If a note is not stored on the platform, clinical quality assurance is arduous; the one-person QA team has to request documentation and the provider has to supply them via HIPAA-compliant delivery method.
A freeform text box does not guarantee everything needed for insurance reimbursement will be captured. And, if the insurance rejects a claim, we have little recourse to appeal.
We could only accommodate a singular billing code: 60-minute therapy session. More complicated billing codes require additional information—like a mental status exam—that is difficult to capture in a freeform text box.

How might we…

The right note format could do a lot of heavy lifting for UpLift.

Quality care is paramount to UpLift’s success. If all notes are completed on platform using the same structure, the UpLift clinical team will be able to perform their clinical quality assurance duties more efficiently.
If we design a progress note format that is compatible with other note types, we will be able to integrate more templates into the product faster. And, if we use structured data, we will eventually be able to help therapists diagnose, generate treatment plans, and choose the proper CPT code.
If we require all the necessary information to submit an insurance claim, our denial rates will decrease.

If notes require a mental status exam (MSE), risk assessment, and include assessment results, providers will be able to bill for more than just a standard 60-minute talk therapy session.
If notes are easier to fill out, providers will submit them sooner, allowing UpLift to kick off a claim to the insurance company sooner and receive payment faster.
Change is hard, and therapists have LOTS of opinions about documentation. If we involve our UpLift therapists and experts in the field in the process, provider NPS will maintain or improve with the launch of the new note template and policy.

Making future proof decisions

Though we were starting with intake notes, we wanted to understand how these choices would eventually impact treatment plans and discharge notes, specifically what inputs could be re-used in other notes or even used to generate parts of other notes.

Solution

Our progress note template was designed to capture everything necessary to conceptualize progress, protect against liability, and submit for insurance reimbursement.

We rely heavily on structured data, which not only make notes easier for therapists to complete—most notes can be completed in 3 minutes or less—but also make it easier for our internal clinical team to perform their quality assurance tasks.

The dynamic form uses progressive disclosure to only show and require information pertinent to the individual client.

Billing made easy

We use the providers’ responses to suggest the correct billing codes.

With just a few clicks…

We are able to generate a personalized note that accurately documents care and conceptualizes progress.

The results

Provider NPS improved 10%.
Time from session complete to note submit decreased by an average of 3 days.
Collaborated with data team to produce rapid QA reports using progress notes, assessments, and caseload data.
We had a template and process for building additional note types.
We leveraged structure data to monitor claim denials and adjust our documentation requirements.
Not only did customer service receive ZERO complaints about the change in policy and structure, we even got positive feedback: