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July 2017

Chart Conundrums: Meeting Postacute Care Needs in an EMR
By Marilyn Altenhofen Dongilli, PT
For The Record
Vol. 29 No. 7 P. 32

Professionals who have spent their careers working in various postacute care environments are all too aware of the lack of an EMR that supports the depth and breadth of services provided in those settings; facilitates compliance with postacute care regulatory requirements such as quality reporting, licensure, and accreditation; and provides documentation-driven scoring of regulatory tools that determine reimbursement (Inpatient Rehabilitation Facility-Patient Assessment Instrument).

An EMR specifically designed to meet the needs of postacute care environments should include the following six features to make life easier for the professionals working in those settings.

Patient Presentation
Due to decreasing acute care hospital length of stays and higher survival rates post medical events, the medical and physical complexity of postacute care patients continues to mount. In addition to a primary diagnosis, patients present with a number of comorbidities with multiple organ/system involvement. This requires an interdisciplinary team consisting of not only a physician, a registered nurse, and a respiratory therapist but also physical, occupational, and speech therapists; a neuropsychologist; a case manager/social worker; an orthotist/prosthetist; a recreation therapist; and spiritual care. These professionals work together to manage the patient's care in order to achieve the optimal outcome of community discharge.

To help reach this goal, the ideal EMR would feature discipline-specific documentation options for all therapies; interdisciplinary documentation that automatically communicates and assists the treatment team in problem solving and care planning for issues such as fall prevention, skin integrity, and line and tube management; individualized care plans that can accommodate the wide variety of patient presentations; and access to evidenced-based practice guidelines and normative values for the initial evaluation and subsequent reevaluation of complex patient types.

The EMR should provide each treating discipline an evidence-based resource for test administration procedures, normative values based on age and gender (if applicable), and interpretative meanings of patient evaluation findings. All of these features assist the clinician and entire treatment team in problem list identification and prioritization, outcome prognostication, and justification for continued stay (inpatient) or visits (outpatient).

Justification for Admission and Continued Stay
Patients admitted to postacute care require a preadmission assessment approved by a physician that ensures regulatory guidelines are met for a specific level of postacute care. This helps to ensure the patient will be admitted to the most appropriate level/intensity of care to maximize recovery. Take note that without this documentation, reimbursement for the patient's entire postacute care stay can be denied, regardless of the outcome.

In addition, postacute care facilities are required to submit documentation throughout the patient's stay to support continued inpatient or outpatient services. The EMR must contain those crucial, postacute care-specific data elements (in every specific discipline) to produce documentation that third-party payers are looking for when reviewing the case for justification of continued services.

Documentation is about not only patient care but also access to care. Without proper documentation, patients may not receive the services they need, neither in inpatient nor outpatient settings.

Federal Regulatory Compliance Requirements
On a regularly scheduled basis, postacute care facilities are required to report specific data on quality measures such as integumentary (acquired pressure ulcers), lines and tubes (central line-associated bloodstream infection, catheter-associated urinary tract infections), and incidence of falls. The EMR must contain these quality reporting data elements to allow clinicians to efficiently and accurately document the required information. More importantly, the EMR needs to provide documentation-driven alerts to ensure the treatment team proactively reacts and prevents potentially adverse complications for the patient.

Inpatient postacute care facilities are reimbursed using diagnosis-related group, rehabilitation impairment category, case mix group, and/or minimum data set (MDS) resource utilization group methodology. Reimbursement is determined based on the interdisciplinary team's discipline-specific documentation of elements illustrating the burden of care.

An EMR that enables clinician documentation to automatically drive element scoring ensures corporate compliance as well as appropriate reimbursement for the level of care provided. This methodology builds on what front-end clinicians do best—evaluate and document patient responses. As a result, front-end clinicians do not have to figure out how to score a patient on various impairment scales or measures. The EMR uses an algorithm to determine the score based on the comprehensive documentation in the patient record.

Aggregating/Managing Data
An EMR should support not only front-end clinicians but also other vested entities such as quality/risk personnel, MDS/quality reporting staff, administrative staff monitoring the productivity and quality of discipline-specific programming, third-party payers, The Joint Commission, and the Commission on the Accreditation of Rehabilitation Facilities.

The EMR that allows front-line treatment teams to focus on patient care and efficient documentation, and is also able to aggregate data in various forms for other vested parties, meets everyone's needs and ensures efficient workflows.

There is seldom a shortage of data in an EMR. Problems typically arise in readily retrieving or even finding the data requested by the vested party. However, a well-designed EMR can aggregate select data for real-time viewing or in a report that can be accessed with a single click, making the hunt for requested information a nonissue.

Workflow Efficiency
There are more than 10 disciplines—each of which has its own workflow and documentation requirements—actively involved with patients in a postacute care setting. For example, nursing and respiratory therapy workflows and documentation are markedly different than those in case management/social work and physical, occupational, and speech therapies. Likewise, postacute care inpatient workflow and documentation requirements differ greatly from their outpatient counterparts.

A smart postacute EMR accommodates each of these workflows and enables all disciplines to work as efficiently as possible. Through this technology, information can be viewed differently from how it may be documented, a circumstance that satisfies all stakeholders. The goal is to work smarter, not harder.

In summary, EMR documentation in postacute care settings has specific requirements to ensure that optimum patient care and patient access to care are assured.

— Marilyn Altenhofen Dongilli, PT, has practiced for 36 years in a wide variety of postacute care settings, with 29 of those years spent at Madonna Rehabilitation Hospitals. Her latest efforts have been devoted to developing postacute care electronic documentation software and teaching clinical documentation at the University of Nebraska Medical Center's Physical Therapy Graduate School.