CHF Patients Reimbursement

CHF Patients Reimbursement within Thirty-Day Readmission


Reducing the rates of readmission is a national priority. It is estimated that readmissions
cost the American Health care more than $ 15 billion annually (McIlvennan et al., 2015). The
National Quality Forum initiated hospital readmissions reduction program (HRRP) aimed at
reducing rehospitalization rates for three highly prevalent conditions: Heart Failure (HF), Acute
Myocardial Infarction (AMI) and Pneumonia (Joynt & Jha, 2013) . This is being implemented by
providing incentives to hospitals that do not exceed a predetermined readmission rates (limit of
3%) while penalizing those that exceed (Bradley et al., 2013) .
Significance of Healthcare problem
One indicator used by Centers for Medicare and Medicaid Services (CMS) to check
health facility’s quality of care is readmission rates. If a healthcare facility has high proportion of
the patients readmitted within 30 days for any disease or condition, then this could be an
indicator of inadequate care delivery (McIlvennan et al., 2015) . CHF (congestive heart failure)
patient care is estimated to consume a staggering 17 percent of the total national health
expenditures and has this has called for reduction of CHF patient readmissions so as to cut down
costs (Yanez et al., 2013) .
Purpose of the study
HF (heart failure) is a chronic condition often accompanied by downstream
complications collectively referred to as Congestive Heart Failure (CHF). The purpose of this
study was to explore whether the reimbursement within thirty-day readmission is justifiable in
case of CHF patients.



Review of the Evidence

The primary function of the heart is to pump blood to the rest of the body. When the
heart has a defect, it does not circulate blood sufficiently and hence the kidney receives less
blood and filters less fluid out of the circulation. As a result, fluid accumulates in major organs
such as around the eyes, legs, the lungs and the liver, a condition technically referred to as
congestive heart failure. (CHF). CHF is chronic disease with symptoms such as fatigue,
sweating, swelling of the feet and around the eyes, and fast breeding. The disease alternates
between stability and worsening and such unpredictable nature has an impact on the patient’s use
of healthcare services and can often lead to preventable hospital readmissions and
reimbursements (Yanez, 2013) .
CHF is the leading cause of hospitalization especially in geriatric population in the USA
(Vinson et al., 1990) . It affects about 5.8 million people. The issue of high readmission rates of
CHF patients has high implication cost to the individual, family and the society. For instance,
readmission rates for patients diagnosed with Congestive Heart Failure (CHF) accounts for $17.4
billion direct cost of care (Centers for Medicare and Medicaid, 2014). Although there is some
progress in reducing mortality in patients diagnosed with CHF, readmission rates continues to
rise with approximately 50% of the patients getting readmitted within 6 months of discharge
(Committee of Presidents of Statistical Societies, 2012 (Joynt & Jha, 2013) ). Worse off, CHF
accounts for about 17 percent of total USA national health expenditures (Yanez et al., 2013).
This trend is projected to increase by five fold in the next decade if no interventions are put in
place to manage the disease (Dearholt &Dang, 2012).



The USA hospitals are committed to improve the quality of care using innovative
programs to strengthen linkage between the various stakeholders. However, most CHF patients
are treated under inpatient option, and in addition to the many challenges involved when
providing CHF patient care, CMS has placed a big burden on the hospitals by introducing an
inappropriate one day length of stay admission and readmission within thirty days. CHF has a
very high readmission rate in the USA which makes healthcare facilities prone to losses due to
potential of becoming fully financially responsible for the CHF patients. AS a result health care
facilities have re-engineered their sytems to avoid readmission costs (Mcllvennan et al., 2015)
For instance, Project RED (Re-engineered Discharge) is a research group at Boston
University Medical Center that develops strategies used by healthcare facilities to reduce
readmission rates. The aim of Project RED is to develop effective strategies in order to promote
patient safety and to reduce readmission rates. The project RED re-engineered intervention is
based on 12 mutually discrete components that reinforce on patient safety and patient
satisfaction. Examples of these components include Visiting Nurse Services, Tele-Health
services, and other community health programs. An intervention study conducted by project
RED reported that patients in the intervention (i.e. Project RED) were less likely to return to
hospital within thirty days of discharge (Jessup, 2014).
Replication of project RED in two separate studies was shown to significantly reduce the
number of CHF patients readmitted hence reducing the cost of healthcare. The Duke University
health system, led by Dr. Christoper O’connor was the first to provide the path to accountable
CHF patient care in the 1990s. Dr. O’connor noted that there was poor coordination
/communication between CHF patients and physicians and there was no access to primary
heathcare for CHF patients. These two challenges, coupled with limited knowledge of CHF



management at that time often led to unnecessary hospital visits. To address these challenges,
Duke University began a program of CHF patient care improvement with three major initiatives,
including the Duke Heart Failure Program, the Heart@home initiative, and Same Day access
clinic (Hernandez et al., 2010).
The Duke Heart Failure Program used a strategy involving multidisplinary CHF care
teams involving cardiologists, nurses, therapists, dieticians and pharmacists and well defined
guidelines (Hernandez et al., 2010; Smith et al., 2014) . The study reported that for patients
enrolled in the program from July 1998 to April hospitalization decreased from 1.5 to 0 per
patient .per year hence saving £8571 per patient per year as a result of reduced readmissions
(Hernandez et al., 2010) . In 2012, the Duke began another study after making some changes such
as putting in place a healthcare team for each patient, improving communication and
coordination between the teams and study sites and patient education on management of CHF
(Hernandez et al., 2010) . On the Same day access clinic study, Duke Researchers conducted a
research study on registry data and found out that the risk of readmission was reduced by seeing
a doctor within 7 days of hospitalization. This study was the basis for the launch of Same Day
Access (SDA) that allowed CHF patients to see a specialist immediately without appointment
(Duke Translational Medicine Institute, 2013) . In these three studies the Duke Team showed that
improved healthcare delivery can significantly reduce readmissions and reduce unnecessary
In another study, like Duke University, Colorado also re-designed its CHF care with
specific focus on use of technological innovation to reduce the length of inpatient
hospitalizations and reduce costly readmissions. Colorado adopted the thirty-day model 4
bundle. In this model, Colorado received a large sum from Medicare and then distributed it to



healthcare providers and if their cost exceeded the set budget, Colorado absorbed the extra costs.
This made Colorado accountable for post-acute care services and hospital readmissions and
significantly reduced the latter (Herman, 2011) . This proved that the 30-day readmission is an
effective and ideal metric for assessing quality and patient safety.


The healthcare system in the USA is in the onset of seismic shifts. The continuing
pressure from different stakeholders to increase healthcare access, increase coverage improve
quality and minimize financial costs will eventually result in a more efficient healthcare system.
CHF is a chronic disease that accounts for a substantial portion of treatment costs of
cardiovascular defects in the USA. As such delivery of CHF patient care is set to evolve due to
these seismic forces. Payers have increasingly shifted to value based reimbursements and this
further affects an already struggling healthcare system. The facilities survival now lies on how
well they will manipulate these financial and logististical forces to their own advantage. One of
those ways will be to put measures in place so as to avoid unnecessary readmissions of CHF and
other related conditions.




Bradley, E., Curry, L., Horwitz, L., Sipsma, H., Wang, Y., and Walsh, M. . (2013). Hospital
Strategies Associated With 30-Day Readmission Rates for Patients With Heart Failure. .
Circulation: cardiovascular Quality and Outcomes, 6(4), 444-450.
Centers for Medicare and Medicaid. (2014). Readmissions Reduction Program (HRRP).
Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and
Guidelines (2nd edition). Indianapolis, IN: Sigma Theta Tau International Lawton, G.
(2010).Tele-health delivers many benefits, but concerns linger. PT in motion journal.
Herman, B. (2011). The advantages and disadvantages of CMS bundle payment initiative: 8
responses. Beckers Hospital Review.
Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammil, B. G., Yancy, C. W., Peterson, E.
D., & Curtis, L. H. (2010). Relationship Between Early Physician Follow up and 30-day
Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. JAMA,
303(17), 1716-1722.
Janice M. Vinson, M. W. R., Jane C. Sperry, Atul S. Shah, and Timothy McNamara. (1990).
Early Readmission of Elderly Patients With Congestive Heart Failure. Journal of
American Geriatirics Society, 38(12), 1290-1295. doi: 10.1111/j.1532-
Jessup, M. (2014). The Heart Failure Paradox: An Epidemic of Scientific Success: Presidential
Address at the American Heart Association 2013 Scientific Sessions. Circulation,
129(25), 2717-2722.
Joynt, K. E., & Jha, A. (2013). A Path Forward on Medicare Readmission. J.Med, 368, 1175-
McIlvennan, C., Eapen, Z., & Allen, L. (2015). Hospital Readmissions Reduction Program.
Circulation, 131(20), 1796-1803. Circulation, 131(20), 1796-1803.
Medicine, D. T. I. (2013). Same day access heart failure clinic provides inter-disciplinary
research oportunities.
Smith, C., Piamjariyakul, U., Wick, J., Spertus, J., Russell, C., & Dalton, K. (2014).
Multidisciplinary Group Clinic Appointments: The Self-Management and Care of Heart
Failure (SMAC-HF) Trial. Circulation: Heart failure, 7(6), 888-894.



Yancy C. W. (2013). ACCF/AHA Guideline for the Management of Heart Failure:
Executive Summary. Journal of American College of Cardiology, 62(16), 1495-1539.

Abstract. The most common indication for readmission
among Medicare patients is congestive heart failure (CHF).

Prior studies underscore the use of residents to bolster hospital-
wide programs and reduce CHF readmissions. The authors

assessed the effectiveness of a novel online training program
designed to improve resident documentation and knowledge
related to CHF. The findings suggest that despite a significant
increase in knowledge scores following the online educational
course, there was only a slight increase in documentation scores.
Additional teaching modalities need to be identified to foster
resident education and create sustained behavior change.

Keywords: congestive heart failure, online education, docu-

T he average rate of all-cause readmissions

within 30 days of discharge among Medi-
care patients is 19.2% and costs approxi-
mately $17.5 billion annually (Jencks, Williams,

and Coleman 2009). The most common indication
for readmission among adults is congestive heart
failure (CHF), accounting for nearly 25% of all
readmissions (Centers for Medicare and Medicaid

Services 2013). Several multidisciplinary interven-
Jay Patel is a medical student at the St. George’s University School of Medicine in Grenada, West Indies. Annia

Cotorruelo-Martinez is a resident in the Department of Internal Medicine at Lutheran Medical Center in Brooklyn, New York.
Nicole Gill-Duncan is a resident in the Department of Internal Medicine at Lutheran Medical Center in Brooklyn, New York.
Philippe Leveille is a resident in the Department of Internal Medicine at Lutheran Medical Center in Brooklyn, New York. Julie
M. Pearson is the clinical research manager in the Department of Clinical Research at Lutheran Medical Center in Brooklyn, New
York. Kell Julliard is the assistant vice president for research in the Department of Clinical Research at Lutheran Medical Center in
Brooklyn, New York. Archana Saxena is a cardiologist in the Department of Internal Medicine, Cardiology at Lutheran Medical

Center in Brooklyn, New York.

Color versions of one or more of the figures in the article can be found online at
tions to reduce readmissions have been developed
and implemented using a systems-based approach,

including transition of care programs, dietary ser-
vices, and visiting nurse services (Shah et al. 1998;

Lasater 1996; Jack and Bickmore 2011). Multidis-
ciplinary interventions are successful at reducing

CHF readmissions, and all-cause hospitalizations
and mortality when specialized follow-up with a

multidisciplinary team is a component of the inter-
vention (McAlister et al. 2004). The inclusion of

medical residents on these multidisciplinary teams
is paramount to improve communication across the

care continuum from inpatient to outpatient set-
tings. A recent study found a lower rate of readmis-
sions among patients tracked by medical residents

in a hospital-wide CHF readmission reduction pro-
gram, compared to the hospital-wide rate during

the same time period (Rabbat et al. 2012). These

findings underscore the use of residents to bol-
ster hospital-wide programs, improve acute inpa-
tient care, and create a shift toward a systems-based


82 Vol. 92, no. 4 2014

approach that bridges the gap from the inpatient to
outpatient settings.
Effective chart documentation is an essential part
of transition of care communication and serves as
a basis for an evidence-based approach to care and
utilization of systems-based resources (Fonarow
et al. 2010). To improve resident knowledge and
awareness of the multidisciplinary approach to
CHF patient care and effective documentation,
we developed a multifaceted educational program,

Physicians Using Modern Practices for Excel-
lent Documentation and Care in Heart Failure

consisted of a novel online education course,
individual training on proper CHF documentation
and a reminder pocket card. Online learning is ideal
for medical residents because of the time constraints

of a busy community hospital setting. Online edu-
cational programs are well suited for disseminating

knowledge-based information and have also been
shown to improve clinical behavior (Shaw et al.
2011). We incorporated the coaching and pocket
card reminder since a multifaceted approach to
learning modalities by using face-to-face elements
in conjunction with online training produces a
larger effect than either alone (U.S. Department
of Education, Office of Planning, Evaluation, and
Policy Development 2010). The goal of this study
was to test the effectiveness of the PUMPED CHF

A multidisciplinary team of cardiologists, resi-
dents, medical students, and researchers was assem-
bled to identify specific areas in which residents

needed to improve their understanding of CHF as
a clinical syndrome requiring primary, secondary,
and tertiary interventions. The PUMPED CHF

program was developed and implemented at a com-
munity teaching hospital in Sunset Park, Brooklyn,

New York. The components of the program are ex-
plained in detail subsequently.

Online Education Course
The online educational program was developed
in accordance with the Accreditation Council for

Graduate Medical Education (ACGME) core com-
petencies and consisted of: training on the relevant

data points necessary for an initial history and phys-
ical examination of a patient with CHF (patient-
centered care), appropriate assessment, daily mon-
itoring, and short- and long-term management

of CHF patients with varying severity (practice-
based learning), evidence-based medical therapy

recommendations from the American College of
Cardiology (medical knowledge), and transitioning

CHF patients to an outpatient setting (systems-
based care). The online course also emphasized doc-
umentation of the listed elements to allow for effec-
tive communication among the multidisciplinary

team caring for the patient.
The curriculum included a framework to guide

residents through clinical assessment and manage-
ment of patients with CHF. The course reviewed

the necessary information needed to complete a
comprehensive history and physical examination in
a patient with CHF. We explained the difference

between systolic and diastolic heart failure and re-
viewed the New York Heart Association functional

classification for CHF patients. The necessary ele-
ments and data points needed to monitor patients

on a daily basis and the incorporation of these find-
ings into daily SOAP progress notes were empha-
sized. The course also described how to document

and classify severity of illness and ensure compli-
ance with core measures and all evidence-based

standard-of-care therapies. Finally, the curriculum
described resources available in our health system

to foster safe transitions to home with home health-
care and physician follow-up within seven days of

discharge. The course consisted of a Microsoft Pow-
erPoint (Seattle, WA) presentation with narration

by a cardiologist expert in systems-based manage-
ment of CHF (Archana Saxena, MD). Residents

were tracked and received frequent reminders to
complete the course to ensure full participation.

Pre- and posttests were used to assess the on-
line curriculum with regard to CHF knowledge

and chart documentation and included fourteen
multiple-choice questions (Table 1). The online test

was immediately scored and displayed the partici-
pant’s score on the computer screen. The internal

medicine PGY-1 class of 2011–2012 completed the
online training.
Individual Coaching

The study team also individually coached res-
idents who completed the online course in the

proper assessment, treatment, and management of

one CHF patient on the medicine floors. Individ-
ual coaching was used as an opportunity to pro-
vide real-time guidance on proper documentation

HOSPITAL TOPICS: Research and Perspectives on Healthcare 83

TABLE 1. Percentage of Residents with Correct Answers on the PUMPED CHF Pre-/Posttest Taken
Immediately Before and After the Online Training (n = 25)
Domain Question Correct score before Correct score after
Documentation only What is the cutoff for an abnormal ejection fraction? 19% 92%

Which of the following are necessary to assess in the
HPI for patients with suspected heart failure?

94% 92%

Where is a good place in the H&P to document prior
cardiac testing?

72% 92%

If a patient comes in with their first heart failure
hospitalization and cardiac echocardiography shows a
left ventricular ejection fraction of 40% (LVEF =
40%), how would you list this problem on the
patient’s problem list?

28% 33%

How often should a CHF patient’s weight be measured
when they are admitted to the hospital?

92% 97%

If a CHF patient has a contraindication to ACE-I/ARB,
what other medication could they be given for
afterload reduction?

78% 89%

After you write in your daily assessment and plan “prior
to discharge, obtain CHF teaching for Mr. Smith,”
who should you ask to provide the CHF teaching and
relevant educational materials to your patient?

64% 89%

After you write your daily assessment and plan, “prior to
discharge, obtain a home health care referral for Mr.
Smith,” who should you ask for help to set up this
vital service for your patient?

86% 89%

Within what time frame should a patient with CHF be
scheduled for a follow-up visit in the clinic or with
their private physician after being discharged?

89% 92%

Knowledge only Why is the Physician Improvement study (PUMPED

CHF) being done?

92% 97%

Is it ever appropriate to write “non-contributory” for
family history or social history when a patient is
intubated and cannot provide additional information?

89% 94%

Which of the following medications have shown the
greatest mortality benefit in CHF patients?

86% 94%

Documentation and

What does the NYHA classification define regarding a

78% 86%

Which ACGME core competency says that residents
should be aware of hospital resources, advocate for
their patients to receive those resources, and
participate in interdisciplinary teams to improve
quality of care?

22% 67%

Note. HPI = history of patient illness; LVEF = left ventricular ejection fraction; CHF = congestive heart failure; ACE-I
= angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; NYHA = New York Heart Association;
ACGME = Accreditation Council for Graduate Medical Education.

of a patient who was currently under the resident’s

The research team designed a logo and made but-
tons that were given to each of the participating

PGY-1 residents upon completion of the individual
coaching to increase awareness of and enthusiasm
for the program. PUMPED CHF buttons were also
distributed to cardiologists, nurses, and support staff
throughout the hospital.

Pocket Card
The residents were also given a 5 × 4 inch pocket
card to keep in their white coat as reminder of the
important elements of CHF chart documentation
(Table 2).
CHF Documentation
To determine the impact of the online course on

actual chart documentation, a 39-point scoring sys-
tem was developed and used to assess charts from

84 Vol. 92, no. 4 2014

TABLE 2. Contents of the PUMPED CHF Pocket Card
PUMPED CHF Documentation Guide
Did you document the following symptoms (positive or negative) on the admitting H+P or ROS?
• Dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Lower extremity swelling
• Mental status assessment
• Subjective weight gain/clothes don’t fit
• Fatigue or weakness worse than baseline
Did you document the following behavior (positive or negative) on the admitting H+P?
• Non compliant with medications
• Non compliant with diet/excessive Na intake (adding salt/eating canned foods or soup)
Did you document the following signs (positive or negative) on the admitting H+P?
• Crackles/rales
• Elevated JVP
• Presence of ascites
• S3 Gallop
• Baseline weight
• Current weight
• Edema
Did you document the following past medical history (positive or negative) on the admitting H+P?
• NYHA Class
• Absence/presence of prior cardiac test with results (on first page of HPI)
• Smoking status
Did you document the following regarding LVEF assessment in the progress note or H+P?
• LVEF (all pts. must be <50% for our study)
• Method of LVEF Determination (i.e. 2D echo, nuclear stress, cardiac cath, MUGA)
• Type of heart failure (i.e. systolic, diastolic)
• Etiology of heart failure (i.e. HTN, ischemic, valvular, non-ischemic, toxin induced, peripartum, tachy induced,
• Acuity level (i.e. acute, acute on chronic, chronic)
Did you document the following regarding discharge medications on the progress note, discharge instructions, or
nursing home transfer sheet?
• Pt discharged with B-blocker?
• If not discharged with a B-blocker, was a contraindication documented? (i.e. bradycardia, hypotension, AV heart block,
asthma, allergy, comfort measures, other)
• Pt discharged with ACE-I/ARB
• If not discharged with ACE-I/ARB, was a contraindication documented? (i.e. angioedema, renal artery stenosis, allergy,
impaired renal function, hyperkalemia, hypotension, pregnancy, moderate to severe aortic stenosis, comfort measures,
• If not discharged with ACE-I/ARB, was patient discharged with hydralazine/nitrates?
Did you document the following regarding patient care on at least one progress note?
• Patient monitoring
• Daily weights
• Ins and outs
• Secondary clinical Interventions
• Smoking cessation advice and counseling provided
• Patient education
• Did the Intern document information regarding patient education for HF?
• Transitions of care: outpatient and follow-up arrangements?
• Did the Intern document information regarding a home health care referral?
• Did the Intern document a follow-up visit within seven days of discharge (suggested or scheduled)
Note. H+P = history and physical; ROS = review of systems; JVP = jugular venous pressure; NYHA = New York
Heart Association; LVEF = left ventricular ejection fraction; MUGA = multiple-gated acquisition scan; BNP = brain
natriuretic peptide; HTN = hypertension; AV = atrioventricular; ACE-I = angiotensin-converting enzyme inhibitor;
ARB = angiotensin receptor blocker; HF = heart failure.

HOSPITAL TOPICS: Research and Perspectives on Healthcare 85
patients admitted and managed by residents. Charts
from the group of residents who took the online
course were compared to a historical control group

of patient charts from residents who had not com-
pleted the course (PGY-1 residents from the pre-
vious year). The same inclusion criteria were used

for both sets of charts and included patients with
systolic CHF, defined as a left ventricular ejection
fraction (LVEF) less than 50%, who were admitted
and managed by PGY-1 residents.
The elements of chart documentation were scored

in five categories. The first two categories per-
tained to signs and symptoms characteristic of a

CHF exacerbation documented in the admission

history and physical, including symptoms of short-
ness of breath, orthopnea, paroxysmal nocturnal

dyspnea, exertional dyspnea, weight gain, and fa-
tigue, as well as documentation of signs such as

presence of rales, jugular venous distension, S3 gal-
lop, ascites, and lower extremity edema. The third

category assessed documentation of items pertain-
ing to daily follow-up and included taking daily

weights and monitoring fluid intake and output

(ins and outs). The fourth category reviewed docu-
mentation for Joint Commission Core Measures for

Heart Failure: discharge instructions, evaluation of
LVEF, angiotensin-converting enzyme inhibitors or

angiotensin receptor blockers for left ventricular sys-
tolic dysfunction, and smoking cessation counseling

and education (Joint Commission Core Measures

Sets 2011). The final category evaluated chart doc-
umentation of classification of illness severity and

etiology, including brain natriuretic peptide levels.

Chart documentation scores are reported as the per-
centage of charts containing appropriate documen-
tation for each item.

Statistical Analysis
Individual pre-/posttest knowledge scores were
downloaded from the online education course and
were compared using a related-samples Wilcoxon
signed rank test for nonparametric data. Data from

the chart review for CHF documentation were en-
tered into an Excel (Microsoft, Seattle, WA) spread-
sheet. Chart documentation from patients with

CHF admitted from August 1 to November 30,
2010 (PGY 1 class of 2010–2011, retrospective
control group) and November 30, 2011 to April

30, 2012 (PGY 1 class of 2011–2012), was com-
pared. All statistical analyses were conducted in

SPSS (IBM, Chicago, IL).

FIGURE 1. Percentage of patient charts with
proper documentation by category. Note: HF
= heart failure.

Online Education Course

Twenty-five PGY-1s completed the online edu-
cation course. Knowledge of CHF documentation

as measured by summative scores (fourteen point
maximum) on the PUMPED CHF pre-/posttest
significantly increased after the online educational
course from a mean of 10.6 (76%) to 12.6 (90%;

p < .001). Scores from individual questions are pro-
vided in Table 1. Pretest scores ranged from 9 to 13

and posttest scores from 8 to 14.
CHF Documentation
A total of 50 charts from the historical control
group and 47 charts from the group of residents
who completed the online training were reviewed.
The mean documentation score of the patient charts
(n = 50) in the historical control group was 46%
compared to 58% in the charts reviewed after the

educational intervention (n = 47; p < .001). Over-
all documentation scores increased in the following

sections: history (from 29% to 36%), daily follow-
up (from 25% to 50%), and characterization of

CHF (from 52% to 78%; Figure 1). Documenta-
tion scores also increased for the Joint Commission

Core Measures for Heart Failure from 61% to 78%.
Improvements in the individual components of the
Core Measures for Heart Failure (Joint Commission
Core Measures Sets 2011) are illustrated in Figure 2.
Resident knowledge of CHF management and
proper documentation significantly increased after
the online education course as demonstrated by an
increase in scores from the pre- to the posttest.

86 Vol. 92, no. 4 2014

FIGURE 2. Percentage of patient charts with
documentation for Joint Commission Core
Measures for Heart Failure (Joint
Commission Core Measures Sets 2011).
Note: LVS = left ventricular systolic; LVSD =
left ventricular systolic dysfunction; ACE-I =
angiotensin-converting enzyme inhibitor;
ARB = angiotensin receptor blocker.
Despite this increase, however, there was only a
slight increase in documentation scores—even with
ongoing mentoring and the pocket card reminder.
We noted a slight increase in the percentage of charts
with appropriate documentation for patient history,
daily follow-up, core measures for heart failure, and

characterization of heart failure; however, the per-
centage of charts with proper documentation was

low in the intervention group. The data from the
chart review suggests that the online component
had a limited impact on clinical behavior change.
Additional teaching modalities in conjunction with
online learning need to be identified in this setting
to improve resident education and training.
Modern educational practices such as online

courses to improve clinical behavior have been de-
scribed in other studies. In one randomized control

trial, a multifaceted educational program utilizing
a blended learning experience successfully reduced
rates of inappropriate oral antibiotics dispensing
(Butler et al. 2012). Another study found that
face-to-face continuing medical education blended
with online spaced education improved providers’
self-reported global clinical behaviors; however,
the investigators did not measure actual clinical
behavior (Shaw et al. 2011). The effectiveness of
Internet-based continuing education workshops on
improved knowledge and clinical behavior can be
comparable or superior to in-person, small-group
continuing medical education workshops (Fordis
et al. 2005).
Online blended learning technologies are widely
promoted as part of continuing medical education

for their flexibility, variety, and convenience (But-
ler 2012), and have demonstrated improved clinical

outcomes (Butler et al. 2012; Shaw et al. 2011;
Fordis et al. 2005; Tamler et al. 2011a; Tamler et al.
2011b), as well as an increase in resident confidence
and knowledge (Tamler et al. 2011b). However, the
impact on clinical behavior is not well understood.
In our study, the increase in knowledge did not
seem to be reflected in the chart documentation.
The slight increase in scores could have been caused
by factors unrelated to the program, such as timing
bias and maturation. Therefore, we cannot conclude

that the online educational course was truly success-
ful in bringing about behavior change. It would be

helpful to identify the key components and tech-
niques utilized in online education that translate

to improved clinical behavior and sustained behav-
ior change. One program that effectively modified

clinical behavior used practice-based outreach, ex-
periential learning, reflection and tailored feedback

(Butler et al. 2012). Increased use of mock clinical
scenarios to demonstrate desired clinical behavior

and increase resident engagement, versus a didac-
tic knowledge-based curriculum, may improve our

behavior-related outcomes. In addition, repetition
of the didactic course and continuous mentoring
may also improve clinical behavior. Repetition is a
technique that is known as a successful method of
teaching cardiac auscultation and may be of value
in the realm of physician documentation as well
(Barret, Ayub, and Martinez 2012).
We did not examine the specific components of
our multifaceted approach that were most effective

in changing clinician behavior unlike other stud-
ies that asked participants to report components of

the intervention that had the greatest influence on

behavior change (Bekkers et al. 2010). It is possi-
ble that the online educational program was suc-
cessful in providing instruction on CHF documen-
tation but that the ongoing coaching was unable

to target specific negative behaviors since residents’
documentation during the coaching may have been
influenced by their being observed. Future studies
should examine each component of multifaceted
programs to determine what is successful; this will
also help optimize cost-effectiveness.
In our study, residents’ documentation improved
in areas related to core measures in CHF such
as documentation of LVEF, type of heart failure,
smoking cessation, and appropriate medication use.

Documentation also improved with regard to dis-
charge planning and pneumonia vaccinations. We

observed little to no improvement in some ar-
eas, such as documentation of daily weights and

HOSPITAL TOPICS: Research and Perspectives on Healthcare 87
compliance with medication, where only 26% of the

charts reviewed after the intervention noted medi-
cation compliance. This could be because residents

rely on verbal statements made during rounds and
thus do not document everything in the chart. The
quality of chart documentation may improve with
the use of electronic medical systems since programs
can be designed to prompt physicians to include
specific information in a standard format. Studies

of the association between improved documenta-
tion and electronic medical records indicate that

systematic documentation practices is not guaran-
teed, however (Hahn et al. 2011).

Modern educational practices, such as online ed-
ucational programs, are a useful training tool for

medical residents because of their adaptability and
convenience. In our study, we found the online

training program to be effective in increasing resi-
dent knowledge but limited in its impact on clini-
cal behavior. Future researchers should examine the

impact of individual components of multifaceted

learning programs to determine what is most effec-
tive in creating sustained changes in behavior.

Resident knowledge of CHF management and
proper documentation significantly increased after
the online education course; however, there was only

a slight improvement in documentation despite on-
going mentoring. Our findings suggest that online

education may not be sufficient to create sustained
change. Additional teaching modalities to use in

conjunction with online learning need to be identi-
fied in this setting to foster resident education and

improvement on a continuous basis