Cerebral is a virtual mental health provider with a mission to democratize access to quality care for all. With several full-service monthly subscription plans to choose from, members have online access to therapists and prescription providers.
Visits are conducted via video chat, and members can message their care team directly. Members can get medications delivered directly to their home.
PROBLEM
Unfortunately, Cerebral’s chart checking process is completely manual, time consuming and costly.
Manual internal audit and monitoring processes require hundreds of hours per month from a team of clinical auditors responsible for identifying each note for audit. To do this, they will go through a process of creating a sample of selected clinicians to review and issues or topics to review for compliance or compliance, and ensuring previous audit findings are not repeated in the environment.
“To get a relevant sample, the monthly manual build process required reviewing hundreds of clinicians’ schedules and appointments to identify and copy medical record links into the EHR to find actual session notes for review,” said Julia Dolan, vice president of behavioral operations at Cerebral.
“The results and observations are then recorded separately in another document, analyzed and summarized into a report for management and individual clinicians, and finally compiled separately for senior management and executive leadership within the company,” she continued.
In addition to being time-consuming, this process is also prone to human error. Successful completion and grading of a supplier audit depends on the auditor’s meticulous attention to detail.
“They are required to enter the clinician name and medical record number into the scoring form used to record feedback,” Dolan explains. “This naturally introduces typical audit risks such as mismatched names, incorrect linkage, or omission of an audit component to the chart.
“We remain committed to continuous improvement and iteration to ensure high quality audit feedback, we have identified gaps in manual processes and remain diligent and proactive with the resources available – this is no trivial task for clinical management,” she added.
PROPOSE
Vendor Brellium has provided AI-powered chart review technology designed to simplify Manage unstructured clinical notes by leveraging artificial intelligence to perform comprehensive, real-time auditing. The technology aims to address a major pain point in healthcare management: inefficiencies and errors in clinical documentation due to manual processing.
“The core function of the system is to pre-screen all unstructured clinical notes for the types of errors and inconsistencies that could potentially impact the quality of patient care and/or insurance billing, such as client sentiment, success and succession, evidence-based interventions, and determining whether treatment goals are measurable and time-bound,” Dolan explains.
“Specifically, the AI is trained to identify clinical errors and detect note trends that may require attention,” she continued. “This preventive analysis also ensures that billing and/or coding errors can be identified and corrected before an insurance claim is submitted, significantly reducing the risk of claim denials and the need for costly rework.”
Furthermore, by automating the review process, the technology promises to reduce the time healthcare providers spend on manual audits by 98 percent, she added. While traditional methods typically allow only a small fraction of patient visits to be thoroughly reviewed, this AI-driven approach allows Cerebral to scale up the proportion of notes it reviews, increasing the scope of reviews while also dramatically reducing the labor-intensive task of manual screening—with a 78 percent reduction in time, she said.
“This dramatic improvement in efficiency has freed up significant resources, allowing healthcare providers to reallocate their time and effort to more customer-focused activities and other administrative areas,” she notes.
Facing the Challenge
In December 2023, Cerebral began using an automated chart review process in its behavioral care department. Faced with the challenge of processing thousands of therapy session notes each month, Cerebral needed a scalable system to ensure compliance with internal quality control and compliance requirements as well as insurance mandates – without the unsustainable burden of manual reviews.
“Our clinical team worked directly with the provider to provide a custom-designed AI system that integrates Cerebral’s unique session note formats, service times, and specific audit requirements of insurance partners,” Dolan explains.
“After building personalized questionnaires and parameters for each note type, Brellium’s system automatically screens session notes from Cerebral’s EHR and flags necessary adjustments, significantly reducing resources spent on administrative audits and freeing up more time for patient care, while minimizing the risk of financial loss due to insurance recovery,” she said.
RESULT
Within six months of implementing AI technology, Cerebral saw a significant 81% improvement in meeting key insurance criteria and a 78% reduction in time spent on chart audits, demonstrating significant improvements in operational efficiency.
Additionally, from March to June 2024, Cerebral saw an 8% improvement in clinicians’ average audit scores.
ADVICE FOR OTHERS
“AI-powered chart auditing has allowed us to scale our document audits in an objective and operationally efficient way,” Dolan said. “It allows Cerebral to more effectively review trends and error patterns through precise data feedback that might otherwise be missed during manual audits.
“In turn, we can more easily identify areas for improvement and better implement additional education across the entire clinician team in a meaningful and impactful way to drive continuous improvement,” she continued.
She concluded that AI-powered chart checking brought meaningful efficiencies to Cerebral’s workflow and improved the quality of note-taking documentation.
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