What Is a Major Issue Facing Payers When Reviewing Documentation From an Ehr?

May 2016

Poor Documentation: Why Information technology Happens and How to Fix It
By Juliann Schaeffer
For The Record
Vol. 28 No. 5 P. 12

The suspects and solutions are as diverse as the viewpoints of physicians and coders.

The health intendance system is awash in clinical documentation, both newspaper and electronic (sometimes a hybrid of the two), from physician and nurse notes to transcribed dictation and more. To put it simply, health care documentation is created by any person who documents within the wellness record, says Tammy Combs, RN, MSN, CCS, CCDS, CDIP, manager of HIM practice excellence at AHIMA.

When documentation is accurate and complete, it works wonders at telling a patient's story and tin can even better patient care. "That story is used in many forums, with the most important existence physician-to-physician communication," says Gina Stewart, RN, BSN, CCS, CCDS, a clinical documentation improvement (CDI) practice director and senior consultant at e4 Services. "The documentation in the medical record needs to be consummate and accurate to facilitate constructive continuum of care."

Nonetheless, no person or process is perfect. It turns out various factors play a part in the cosmos of "poor documentation," including compliance concerns and time constraints. Provider instruction seems to be another big piece of the puzzle. On the plus side, that's a problem with a fairly straightforward solution.

Poor Documentation Divers
Earlier tackling a documentation trouble, wellness care organizations must elucidate whether indeed at that place is a problem in the starting time place. Determining the specifics of what constitutes poor documentation is the offset step.

According to Drew Chiliad. Siegel, Dr., CCDS, CPC, a CDI specialist at MedPartners HIM, documentation quality depends on who is using a detail wellness record—and for what means. For physicians, documentation that impairs patient evaluation and/or handling would receive poor marks. For a coder, "poor documentation would be defined every bit documentation that lacks the sufficient specificity to assign accurate diagnosis and process codes," Siegel says.

In full general, Stewart says poor documentation is defined as that which is lacking clarity, specificity, or abyss, and is of overall poor quality.

"Documentation that fails to concisely convey a patient'southward problem and the logic used to address that problem risks patient safety and obfuscates any effort to estimate the quality of the rendered intendance," says James L. Whiteside, Doc, MA, FACOG, FACS, residency programme director and an acquaintance professor of obstetrics and gynecology at the University of Cincinnati College of Medicine. "Failing to estimate the quality of the rendered care makes estimating the care value impossible, given value is defined as the quotient of care outcomes and care cost."

In essence, poor documentation is anything that inhibits a articulate presentation of a patient'due south story, Combs says. "For case, if a provider is documenting congestive heart failure, he or she will need to include the acuity and blazon of congestive center failure to ensure the highest level of specificity," she says. "Instead of just documenting congestive heart failure, which is unspecified, he or she could certificate astute on chronic systolic congestive middle failure, which would accept the diagnosis to the highest level of specificity. All other notes should reflect intendance and handling to back up the astute on chronic systolic congestive middle failure."

While that may seem like a small issue of semantics to those outside—and even some inside—the health care organisation, its potential ramifications are real and significant. "The ramifications of poor documentation are endless," Stewart says. "They start at the front line and, nigh importantly, with patient safety issues. From at that place, the opportunities flow into financial repercussions for the facility. The consequences of poor documentation all come full circumvolve."

Combs says the consequences extend beyond quality reporting and appropriate reimbursement. "High-quality clinical documentation is not only important to obtain appropriate reimbursement and authentic quality scores merely information technology is also an obligation to provide accurate data to patients," she says. "Patients rely on reporting agencies to make health intendance decisions. For patients to make informed decisions, there must exist authentic information available for them to review."

Although documentation serves many purposes, Siegel believes its major focus is to provide effective patient intendance. Failure to properly document can have severe consequences, resulting in the post-obit:

• incorrect treatment decisions;

• expensive, painful, and/or unnecessary diagnostic studies; and

• unclear advice between consultants and referring physicians, resulting in a lack of follow through with evaluation and treatment plans.

Factors at Play
At that place is no one factor that alone causes lackluster documentation, merely many CDI experts cite bereft provider education near the height of the list. "Providers typically practice non understand all facets of the health care industry," Stewart says. "They are also extremely busy, and so it is very difficult to provide thorough education. Information technology needs to be understood that physicians are adult learners; therefore, a modified arroyo needs to be taken when it comes to educating them."

Combs agrees: "The most common cause of poor documentation is a lack of understanding of the specific information that needs to be included for coding purposes. Physicians tend to document a lot of information; yet, due to a lack of pedagogy, they do not utilise the words needed to provide the highest level of specificity."

It'south of import to notation that proper documentation isn't going to be learned on the task or past happenstance. "When querying a medico regarding the medical record, y'all will never obtain positive results in the long run if yous practice not educate them on the eventual outcome and purpose behind the initiative," Stewart says.

Provider know-how isn't the only factor at play. Time likewise appears to be against providers. "I believe that the amount of patients that a provider—specially a medico—is required to see in a day leads to a tug of war," says Denise Buckland, RN, senior vice president of operations and vice president of clinical programs at the International Medical Group. "The provider'southward get-go feeling is of obligation to the patient. They spend their express corporeality of time providing the patient care, and the documentation becomes the secondary priority."

Simply at that place's got to be more to it, Whiteside says. "The boilerplate US physician visit is effectually 15 minutes. In Japan, the average medico visit is betwixt 3.5 and iv.5 minutes," he notes. "More physician time could assist the documentation problem, but this ignores the reality that at that place are poor incentives for clinicians to provide great documentation and there are poor systems to overcome that bias."

Whiteside says EHRs attempt to promote better documentation, merely the event is mixed at best. "The HITECH Act did much to force ameliorate documentation via wider adoption of EHRs, simply getting physicians to fundamentally modify how they process clinical information is more just providing an electronic format that may but perpetuate bad habits," he says.

EHRs have solved many legibility concerns, and even improved communication amongst providers. Just the engineering science has also led to major concerns about copying and pasting within medical records. "Copy and paste has go so rampant that nearly any inpatient record of any patient in about whatsoever hospital is bloated with the same assessment and plan reiterated across time and which, beyond being sloppy, may impair original thinking," Whiteside says.

According to Siegel, EHRs have the capability of improving documentation in the long term—if certain boxes are checked first. Specifically, he says, information technology's necessary for software vendors to work closely with users—both clinicians and coders—to make meaningful adjustments.

In that location also are compliance concerns, which, according to Combs, are always at the forefront of health intendance organizations' thought processes. As they should be, Siegel says—to an extent at to the lowest degree. Value-based purchasing and other reimbursement bug (such equally audits), patient rubber indicators, and hospital-acquired conditions are dependent on authentic documentation. But if physicians are documenting as they should, Siegel says there's piddling to worry near.

"Malpractice considerations are important, but if the medical tape accurately portrays the patient'south condition and describes how evaluation and handling decisions were made, then documentation is sufficient for these purposes," he says.

How to Address the Trouble
To amend documentation, Whiteside suggests establishing provider education at the classroom level. "Medical education has to alter how clinical controlling is taught," he says, calculation that HIT must be better integrated into that teaching so that would-be physicians learn what does and does non work. "For hospitals, this effort has to work meantime with existing practise, since clinical medicine cannot stop, retool, and first upwards once more."

Information technology takes investing in more but HIT, Whiteside notes. "Possessing a well-staffed, dedicated squad of physicians savvy in It and medicine who can work amongst physicians also decorated or disinterested to accept on the task of tooling the EMR to perform better is critical," he explains. "Likewise often that need is not prioritized by hospitals, given information technology does not contribute to the hospital margin. Likewise, if these data confirm that the surgical robot renders no improvements in clinical outcomes or costs, a prized marketing attempt may be threatened."

For health care organizations unsure of whether their clinical documentation is falling short, Combs recommends performing a gap analysis. "Past reviewing the case mix index (CMI) and seeing where you are compared to other organizations that provide the same type of services would be the kickoff footstep," she says. "If the CMI is significantly lower than their peer, they either have healthier patients or the documentation does not back up true acuity of their patient population."

To identify a potential documentation event, Whiteside recommends gathering an expert content team to focus on a measurable process. "Look at the documentation leading upwards to and after that process," he says, while suggesting the following questions be addressed:

• Did the documentation logically point to the need for the procedure?

• Was the procedure adequately described?

• Was the care post-obit the procedure described properly to rail the outcome?

When deficiencies are found, if possible, revisit the EMR to program remedies, he says.

A gap analysis may exist office of a broad-ranging CDI programme. "The CDI team tin provide ongoing record reviews and didactics to providers," Combs says. "Upkeep constraints may be an issue, so following the gap analysis volition guide the development of the CDI squad. The team may need to start small and grow and see where the greatest furnishings are."

CDI programs vary depending on several factors, including organization type and workflows. Withal, Siegel says near hospital inpatient-based CDI programs perform the following functions:

• Review patient medical records to identify incomplete documentation of diagnoses (specially secondary diagnoses).

• Apply compliant queries to accost identified documentation improvement opportunities with the provider.

• Identify potential patient condom indicators and hospital-acquired weather and query when necessary to clarify whether or not these weather condition were present on admission.

• Provide education opportunities to clinicians.

"This education should include explaining that accurate and complete documentation improves patient care and impacts their profile on outlets such as Healthgrades, Consumer Reports , the Centers for Medicare & Medicaid Services, and insurance providers," Siegel says. "It should too explain the importance of capturing diagnoses that impact severity of illness and hazard of mortality assignments that profiling organizations utilise to compare the quality of intendance provided by hospitals and physicians."

According to Stewart, successful CDI programs are driven past the overall quality of the documentation, an approach that puts to residual the idea that the facility is "simply looking for money" and facilitates physician buy-in. "When CDI staff are well versed in non only complications and comorbidities (CCs) or major CCs but as well severity of disease and hazard of mortality, information technology provides motivation to the physician to sympathise the goals and piece of work with the organisation to achieve meliorate documentation. They realize that the initiative also benefits them."

Doctor buy-in is a must, Siegel says. "It is imperative that physicians and other clinical administrators be included in whatever plans made to address and right these issues," he says.

CDI efforts are no like shooting fish in a barrel win, notwithstanding, and can come with challenges of their own. The initiatives, and CDI staff, that show flexibility are more than likely to win the mean solar day. "For example, if there are limited resources bachelor when developing a CDI programme, the organization may desire to focus on one payer group, such equally Medicare, at start," Combs says. "Equally they run into success in the quality reporting for that grouping, they can move on to others in the system."

If resources are limited, Siegel says a mindset reset for administrators may be all that's needed. "Administrators must understand that successful documentation improvement programs and accurate coding will often result in higher reimbursement and thus improve resources limitations in the long term," he says. "Administrators must support and adequately fund and staff CDI and coding departments from the offset to achieve maximum results."

It may take more resources than an arrangement would adopt, but it's an endeavor, if washed correctly, that can pay off many times over, Whiteside says.

"This is an expensive effort, and for much of that attempt it's not conspicuously known how information technology should be washed all-time," he says. "The mess, still, has been perpetuated long enough. Develop the expertise among physicians in training to have the workforce necessary to meaningfully turn things around. For existing hospitals, start small and take the courage to respectfully share the findings of the quality improvement cycle [with physicians]. Competitiveness can be a powerful motivator for physicians to modify, and in many cases the problems are unknown to the physicians given that they take non been held to any standard in the by."

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.

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Source: https://www.fortherecordmag.com/archives/0516p12.shtml

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