Missed Opportunity? Dont Dismiss Documentation
Facilities not focusing on physician documentation are missing a huge opportunity, says Richard Paula, MD, CMIO of Tampa General Hospital (TGH) in Florida. "EMRs allow for coding and IT teams to interact with physicians in a way that was not possible before EMRs existed."
TGH transitioned from a paper-based clinical documentation improvement system to a new model upon its implementation of EMRs. Rather than send nurses to track down physicians for additional documentation, the process now is rolled into the facility's concurrent coding program using an e-documentation query process. That allows for real-time coding of records and electronic communication with physicians.
"The beauty of an electronic query within the EMR is that when the physician responds to that query, it automatically becomes part of the documentation," says Rosalia Flora, MBA, manager of the concurrent coding and the documentation query programs at TGH.
Effectively communicating in real time can help facilities and patients in numerous ways. For instance, TGH's documentation specialists work to track the top issues identified by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission, such as hospital-acquired conditions.
The process allows the team to track another important challenge—identifying conditions that were present on admission. "We can ask that question directly of physicians when the condition is documented through a drop-down menu," Paula says. Specifically, the physician is presented with a drop-down box to select from, allowing he or she to simply click and sign.
The "streamlined process minimizes the effort put on very busy physicians," says Paula.
Another benefit of the concurrent program is the capability to use those data to support other quality measures. "We can identify certain patients more quickly during their hospital stay and make sure they get appropriate interventions," says Flora, rather than identifying those patients after discharge, when it's too late.
TGH's clinical documentation improvement (CDI) program also is laying the groundwork for the greater specificity required with the upcoming transition to ICD-10, says Flora. "With ICD-10, the number of possibilities for a code assignment is going to quadruple. The specificity of documentation is vital. Now, by using real-time documentation queries, we're helping physicians understand the importance of documentation."
In addition to the documentation demands of ICD-10, audits call for intense scrutiny of clinical documentation, says Trey La Charité, MD, hospitalist, physician advisor for the University of Tennessee Medical Center's Clinical Documentation Integrity Project, and advisory board member of the Association of Clinical Documentation Specialists. He also serves as the physician advisor for coding where his responsibilities include the formulation of all recovery audit contractor appeals that involve coding and documentation issues.
La Charité became an excellent documenter during his residency when he treated all coding patients regardless of service. "I cannot tell you how frustrating it is to pick up the chart of someone who just arrested and has been in the hospital for three weeks and there's nothing written down." Meanwhile, La Charité is tasked with treating the patient's emergent condition.
Self-described as "anal-retentive," he says that writing an extensive note makes him feel that he has thoroughly examined the patient. "When I know everything, I'm more likely to get it right and less likely to make a mistake."
Flora also cites the importance of continuity of care. As a tertiary care facility, TGH often has patients transferred from outside facilities and the electronic documentation query process helps ensure that "the documentation is there and complete when patients are transferred in or out of our services."
More than one physician was negative about the process before really trying it out, she says. "Once they understood the process, they became champions. That's just fantastic because peer-to-peer pressure among the physicians is always going to go beyond anything we can do."
To get physicians engaged in documentation improvement, La Charité suggests showing them the difference between the language and terminology physicians use and what exists in the code books. Most physicians are "just not aware that there is a huge gap between those two realms."
TGH made a point to get the medical director involved early in the process to create queries that made sense to both the coders and the physicians, Paula says. Today, the query response rate continues to improve because "we work with physicians to provide education and a continual process of communication," he says. As the hospital's staff gains experience with the EMR itself, they become more familiar with the query process.
Reimbursement is a component of any CDI program but it is a short-term goal, La Charité says. "The long-term goal has to do with all of physicians' data and hospital data being put out on the web for the public to view." Based on those data, will patients want to continue to come to your facility and see your physicians? If the data indicate worse outcomes than other nearby facilities, insurance companies might not want to cover services rendered at your facility.
But the bottom line is important. Pre-existing conditions, for example, must be documented accurately, says Paula. "It's not very fair for the hospital to be penalized by CMS for conditions patients had prior to their arrival here just because those conditions weren't documented adequately." It's also pertinent to note, however, that "what we're doing is clarifying documentation. We are not adding anything or coercing physicians. We're just clarifying because there is some reimbursement at risk."
EMRs autopopulate with certain data points, such as new vital signs and lab results. Once a doctor inputs documentation with a certain level of specificity, it's much easier to propagate that content from day to day, La Charité says, but he cautions that "any physician will look to save time. The concern is that he or she will just duplicate one progress note for four days." While cloning should not be allowed, copying and pasting certain elements, such as the problem list, is acceptable.
The most efficient way to launch a CDI program is to choose an experienced outside vendor, he says. With meaningful use quality measures, greater outcomes transparency, ICD-10 and more, there's plenty of reason to drill down on documentation.
TGH transitioned from a paper-based clinical documentation improvement system to a new model upon its implementation of EMRs. Rather than send nurses to track down physicians for additional documentation, the process now is rolled into the facility's concurrent coding program using an e-documentation query process. That allows for real-time coding of records and electronic communication with physicians.
"The beauty of an electronic query within the EMR is that when the physician responds to that query, it automatically becomes part of the documentation," says Rosalia Flora, MBA, manager of the concurrent coding and the documentation query programs at TGH.
Working together works
Flora's team worked with IT and the physicians themselves to create documentation templates and smart text that aids in quicker, more complete documentation. Simultaneously, the health information management team worked with the physicians on how to answer documentation queries, such as what types of information to clarify and what to describe more specifically to apply an accurate ICD-9 code.Effectively communicating in real time can help facilities and patients in numerous ways. For instance, TGH's documentation specialists work to track the top issues identified by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission, such as hospital-acquired conditions.
The process allows the team to track another important challenge—identifying conditions that were present on admission. "We can ask that question directly of physicians when the condition is documented through a drop-down menu," Paula says. Specifically, the physician is presented with a drop-down box to select from, allowing he or she to simply click and sign.
The "streamlined process minimizes the effort put on very busy physicians," says Paula.
| University of Tennessee’s team consists of four clinical documentation nurses, a coding quality coordinator, a medical records manager and a unit clerk. La Charité strongly recommends an effective physician champion because, “let’s face it; most physicians respond much better and take direction better from other physicians.” The Tampa General Hospital CDI team is comprised of 14 full-time employees who cover more than 1,000 inpatient beds and enhanced by four contract coding specialists as needed. |
Another benefit of the concurrent program is the capability to use those data to support other quality measures. "We can identify certain patients more quickly during their hospital stay and make sure they get appropriate interventions," says Flora, rather than identifying those patients after discharge, when it's too late.
TGH's clinical documentation improvement (CDI) program also is laying the groundwork for the greater specificity required with the upcoming transition to ICD-10, says Flora. "With ICD-10, the number of possibilities for a code assignment is going to quadruple. The specificity of documentation is vital. Now, by using real-time documentation queries, we're helping physicians understand the importance of documentation."
In addition to the documentation demands of ICD-10, audits call for intense scrutiny of clinical documentation, says Trey La Charité, MD, hospitalist, physician advisor for the University of Tennessee Medical Center's Clinical Documentation Integrity Project, and advisory board member of the Association of Clinical Documentation Specialists. He also serves as the physician advisor for coding where his responsibilities include the formulation of all recovery audit contractor appeals that involve coding and documentation issues.
La Charité became an excellent documenter during his residency when he treated all coding patients regardless of service. "I cannot tell you how frustrating it is to pick up the chart of someone who just arrested and has been in the hospital for three weeks and there's nothing written down." Meanwhile, La Charité is tasked with treating the patient's emergent condition.
Self-described as "anal-retentive," he says that writing an extensive note makes him feel that he has thoroughly examined the patient. "When I know everything, I'm more likely to get it right and less likely to make a mistake."
Flora also cites the importance of continuity of care. As a tertiary care facility, TGH often has patients transferred from outside facilities and the electronic documentation query process helps ensure that "the documentation is there and complete when patients are transferred in or out of our services."
Successes outweigh failures
As with any new effort, TGH has had successes and failures. "Our successes have outweighed our failures," Flora says. "I have been pleased and surprised at how responsive the general medical staff has been to using the electronic documentation query function. Once they see how easy it is, they just love it."More than one physician was negative about the process before really trying it out, she says. "Once they understood the process, they became champions. That's just fantastic because peer-to-peer pressure among the physicians is always going to go beyond anything we can do."
To get physicians engaged in documentation improvement, La Charité suggests showing them the difference between the language and terminology physicians use and what exists in the code books. Most physicians are "just not aware that there is a huge gap between those two realms."
TGH made a point to get the medical director involved early in the process to create queries that made sense to both the coders and the physicians, Paula says. Today, the query response rate continues to improve because "we work with physicians to provide education and a continual process of communication," he says. As the hospital's staff gains experience with the EMR itself, they become more familiar with the query process.
Reimbursement is a component of any CDI program but it is a short-term goal, La Charité says. "The long-term goal has to do with all of physicians' data and hospital data being put out on the web for the public to view." Based on those data, will patients want to continue to come to your facility and see your physicians? If the data indicate worse outcomes than other nearby facilities, insurance companies might not want to cover services rendered at your facility.
But the bottom line is important. Pre-existing conditions, for example, must be documented accurately, says Paula. "It's not very fair for the hospital to be penalized by CMS for conditions patients had prior to their arrival here just because those conditions weren't documented adequately." It's also pertinent to note, however, that "what we're doing is clarifying documentation. We are not adding anything or coercing physicians. We're just clarifying because there is some reimbursement at risk."
EMRs autopopulate with certain data points, such as new vital signs and lab results. Once a doctor inputs documentation with a certain level of specificity, it's much easier to propagate that content from day to day, La Charité says, but he cautions that "any physician will look to save time. The concern is that he or she will just duplicate one progress note for four days." While cloning should not be allowed, copying and pasting certain elements, such as the problem list, is acceptable.
The most efficient way to launch a CDI program is to choose an experienced outside vendor, he says. With meaningful use quality measures, greater outcomes transparency, ICD-10 and more, there's plenty of reason to drill down on documentation.
| Get Physicians On the Same Page |
| "Physicians themselves are the biggest problem" when it comes to clinical documentation, says Wendy Whittington, MD, MMM, chief medical officer for Anthelio, an IT and business process services provider for the healthcare industry, and a practicing pediatrician in New Jersey. The fact is "there's so much other change going on within healthcare that is not necessarily in synch with these efforts." Data silos within organizations and the lack of good strategic planning are just two barriers to proper documentation. With the shift to EHRs, "it's not always just about what the doctor writes but what he or she has available on the menu," she says. It's "sad but true" that the people who build EHRs could care less about clinical documentation, she adds. The clinical documentation improvement (CDI) team has no visibility to the IT and EHR teams, she says. Different goals also can be a problem. Whittington cites those who are working to meet meaningful use requirements and those on the financial side looking for the best diagnosis-related group (DRG) for payment. Organizations must work harder to get everyone on the same page since so many efforts overlap. Physicians who understand revenue cycle and reporting requirements can be tremendously helpful in bringing issues to the forefront and effecting change, Whittington says. They also can help their colleagues understand that bucking the CDI program not only hurts the hospital financially but hurts each physician. As we move to an era of pay-for-performance and value-based purchasing, more accurate documentation and coding becomes more relevant to physicians on an individual basis. As we plan for the transition to ICD-10, "I tell physicians they have nothing to lose by documenting today in a way that is complete enough for a coder to translate that into an ICD-10 code." The sooner that physicians document with that level of specificity, the better, she says, because it may help coders get patients into better reimbursement categories and help physicians get into better habits. "The amount of specificity required with ICD-10 really is humongous compared with ICD-9 so I advise doctors to bite it off in little pieces," she says. For example, physicians are going to have to identify laterality. Documenting "otitis media" won't be enough—they will have to indicate whether it's right or left. "The list goes on and on. Physicians should pick off some of the easy ones now so it's not so painful of a learning curve and the adjustment in 2014 is not as big." |
Beth Walsh,
Editor
Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.