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September 29, 2008

Chart a Course for Better Documentation
By Selena Chavis
For The Record
Vol. 20 No. 20 P. 30

More than ever, physician documentation plays a critical role in the quality of patient care and revenue cycle management. Getting providers to raise the bar in this area will be a crucial aspect of care going forward.

Beth Kost-Woodrow, chief privacy officer and executive director with Georgia-based Wellstar Health System, views the need for improving physician documentation as no small matter, “It’s a national issue at this point.”

 From patient safety and outcomes to compliance and the revenue cycle, Kost-Woodrow says it’s the one piece that sets the stage for success or failure in many areas of hospital operations and patient care. In fact, getting physicians to adopt best practices in this area may be one of the greatest challenges facing today’s healthcare organizations. The intricacies associated with rules such as Medicare severity diagnosis-related groups (MS-DRGs), present-on-admission indicators, and ICD-9 codes make it that much more critical to get everyone on the same page.

Consider congestive heart failure (CHF) as an example. Under the new MS-DRG system, Kost-Woodrow points out that documenting simply CHF is no longer specific enough. It means a hospital will not get the appropriate reimbursement unless more detailed information is available in the physician documentation.

“Knowing whether it’s chronic or acute CHF is so important,” she emphasizes. “I think a lot of physicians are just used to writing CHF.”

While conformity with new rules directly impacts a hospital’s revenue cycle and compliance, Kost-Woodrow says the heart of the documentation issue extends to improving patient safety and making better decisions across the continuum of care.

“Anyone who reads a newspaper knows about medication errors,” she says, pointing to higher scrutiny from regulatory bodies, The Joint Commission, and consumers alike. “Also, there are so many consumers putting together personal health records that documentation becomes even more important because patients want to know more about their medical information.”

All of these pieces coming together may be the precursor to renewed interest in documentation improvement programs, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems. “With the increased need for specification, there has been a greater need for documentation improvement teams,” says Garrison, who points out that interest in such programs grew in the ’90s but later waned. “In general, the organizations do not have an understanding of documentation’s impact. They’ve done little to assess their weaknesses.”

Perhaps the declining interest in documentation improvement programs in the late ’90s came as a direct result of physician resistance, says James Kennedy, MD, a general internist and director of the Atlanta-based consulting group FTI Healthcare. “For many years, this whole documentation issue only supported hospital reimbursement,” he notes, pointing out that there was no other compelling reason for physicians to step up to the plate. “That message worked with physicians only to the extent that they wanted to support their hospital and its interests.”

As hospital and physician profiling on the Internet has increased scrutiny, many experts suggest that attitudes are changing and the time may be ripe for a renewed focus on documentation improvement programs. Experts say there are steps that can help engage physicians and enable them to take ownership of the content they provide in patient records.

Establish and Equip a Solid Team
While many models exist for putting an effective documentation improvement team in place, the one element that seems to drive success across all areas is the involvement of a chief medical officer or medical director.

“There is no substitution for getting [direction] from a peer,” says Donna Schultes, director of clinical informatics at New York-based A.O. Fox Memorial Hospital, a rural community health network with 900 employees and a medical staff of more than 70.

Kennedy agrees, noting that during his tenure as a consultant to physicians on topics of documentation, one of the keys to his success in engaging this group rests in the fact that he can speak from experience. “We understand each other,” he says, adding that using service line medical directors, such as a cardiology medical director, to educate on specific issues is also effective.

Garrison notes that she usually sets up an executive team, identifying one person to “own it.” The team could be comprised of key professionals from HIM, case management, utilization, or quality control.

“These programs are usually housed in case management, HIM, or quality. All of these models can work,” she says, cautioning that issues often arise with physicians if this function reports to finance.

Kost-Woodrow says that while having case management leadership run the program is often a good approach, asking case managers to be accountable for the documentation improvement tends to become problematic. “Case management is challenging and time consuming enough,” she says. A better approach may be to create a specific position for a documentation specialist.

Establish Ownership
Several experts recommend focusing on how proper documentation can improve quality, not its role in boosting finances, because physicians tend to become disinterested or defensive if it’s all about money.

Kennedy says the growing number of physician rating Web sites makes it in the best interest of doctors to get engaged in this process. “Try to show them how it impacts them. The fortunes [hospital and physician] are now shared,” he says. “How will the public get the message that they are doing a good job unless the coding reflects them doing a good job?”

Pointing to Web sites such as HealthGrades.com, Kost-Woodrow says physicians are becoming more educated about the information that can be found on the Internet and are much more open to getting involved. “That’s really helping us have conversations with our physicians because they care about it. Some of them are starting to approach us for help with improving their documentation,” she says.

Garrison suggests that healthcare facilities do their research and show physicians how their outcomes and death rates compare with local, regional, and national data. “They want to know their own results, not just the industry’s results,” she says.

Schultes adds that healthcare organizations can help physicians gain ownership of documentation improvement by allowing them to become involved in the process from the beginning, including encouraging feedback about products and solutions that are designed to help. “It’s very important that they have a voice in this,” she says.

Focus on Specialties
While across-the-board training may be an efficient way to approach documentation improvement initiatives, experts say that taking time to focus on individual specialties can bring big wins and payoffs.

“Sometimes you get some more specific teaching opportunities when you are working with specialties,” Schultes says. “The dialogue becomes more specialized and meaningful.”

For example, Schultes points to physicians working in labor and delivery. The care typically takes place over a shorter time period than some other conditions, making the documentation more focused and acute in nature. She notes that a fetal heartbeat would be documented in a more acute fashion than that of an older patient recovering from a general surgical procedure without complications.

Garrison notes that often, if a hospital will identify its high-volume patient diagnoses, as well as a few hot topics by specialty, it can achieve success more quickly. Once the high volume issues are accounted for, she suggests tackling the more minor issues by specialty and department.

“We train physicians by department and specialty, but we also train ancillary departments in the hospital,” she says, pointing to departments such as dietary, emergency, wound care, and nursing. “We look at the hospital structure to see who is doing the bulk of documentation on patient care.”

Going One on One
In the same vein as focusing on physician specialties, hospitals can boost documentation by identifying high-volume admitters and physicians who tend to be more problematic than others. A dose of one-on-one consultations and training could be the tonic to get this group on track.

“I have had [hospitals] give me a list of ‘doctor difficults’,” says Garrison, who believes sometimes the issue is just a lack of education.

Schultes points out that the documentation requirements for hospital-based doctors tend to be more stringent than those in a private practice, and hospital educators should be ready to point out these key differences. “The risk management issues are basically the same—you certainly want to have the most complete documentation you can have,” she says. “It’s the formulation and depth of the documentation that may look a little different.”

Kennedy notes that while the codes are the same, the primary differentiator is that the incentives in a hospital are driven by diagnosis. “Diagnosis sets the reimbursement rate,” he says. “In an outpatient setting, the diagnosis regulates the level of service provided.”
Pointing out that one-on-one training can tax hospital resources, Kost-Woodrow suggests that such facilities need to do their research as to who and where they will get the most bang for their buck to make the effort realistic and worthwhile.

A.O. Fox Memorial found success in offering a number of training models to physicians—group, online, and one on one. “Most physicians in my experience will use a combination,” Schultes says.

Make It Easy
There may be an initial investment of resources and training involved in automation, but most facilities that have implemented technology solutions to help provide documentation information in real time have reaped noteworthy benefits.

“You really can’t underestimate the value of [automation] and how powerful it is to providers in their decision making,” says Schultes, who points to A.O. Fox Memorial’s recent implementation of MedPlus technology. “Information being available across the continuum of care is just vital from a patient safety perspective.”

Often, technology geared toward improving the process will have built-in tools capable of identifying potential documentation problems, as well as quick and easy ways for coders to reach physicians when questions arise. And that can only help in the wake of MS-DRGs, says Kost-Woodrow.

Pointing to the effects of MS-DRGs, she notes that the decrease in productivity experienced by coding staff at Wellstar has been an enormous challenge. “If you really want to have quality in your secondary diagnosis coding, you really have to have good documentation and take the time to code accurately as a result,” she says.

Include Midlevel Providers
Experts agree that physician assistants and nurse practitioners continue to be major factors in terms of documentation in the patient chart. Educating these professionals on the same level as physicians is imperative to a solid documentation improvement program, says Kennedy.

“They have a clinical role because they often are the only ones writing in the charts,” he says, pointing out that from a training perspective, there really should not be a differentiator between midlevel providers and physicians. “Physicians may or may not review the documentation to the level they should.”
Kost-Woodrow agrees, noting that Wellstar “has a strategy to work very closely with that group because they are providing so much of the documentation now.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

Typical Documentation Challenges

In the following example, Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems, provides insight into the inherent challenges involved in effective documentation:

Ms. Smith presented to ED today with near syncope, blood pressure of 80/40, temperature of 102, Glucose of 390, positive Urinalysis and a WBC of 17.9. Blood and urine cultures have been ordered, and she was admitted for further workup and treatment. She has a history of long-standing diabetes requiring insulin twice a day, and her blood sugars have been ranging from 180-440 in the past three weeks. She has a history of COPD, PVD, gastroparesis, and vision problems. Today, her lab values also reflect an elevated BUN and a Creatinine of 2.4. She is being admitted with an initial diagnosis of UTI and diabetes.

“This example shows many documentation issues that need to be clarified,” Garrison notes, citing the following:

• blood pressure of 80/40;

• diabetes, type, manifestations, and control status (ie, are the PVD, gastroparesis, and vision problems manifestations?);

• indications of BUN and creatinine results; and

• results of blood and urine cultures and their indications.

In her 16 years of working in the documentation improvement realm, Garrison has found the most common issues to be the following:

• contradictory information (attending and specialists contradict each other: CVA vs. TIA);

• abnormal lab and diagnostics without further explanation, diagnosis;

• medications without documentation of medical conditions they are treating;

• physician orders for treatment plans with no corresponding diagnoses;

• conditions not ruled in or out from the differential diagnoses;

• terminology issues between clinical and coding (urosepsis); and

• lack of specificity (with or without exacerbation, acute vs. chronic, etc).

— SC