Integration of Care Must be reflected in the New Clinical Documentation Paradigm

Many private practice Clinicians and those on Medical staffs, especially those in Faculty Practices are struggling to find the proper balance between integrating Patient Care and achieving a high degree of proficiency in doing ICD-10-CM/PCS Claims.  Is there a dichotomy between those goals of Integrated Patient Care Management and satisfying the kind of specificity and critical thinking required by CD-10-CM/PCS?

Health Systems Management Network, Inc. in its Clinical Documentation Improvement Programs over the past 30 years has collected much data which might answer the question of the perceived conflict between the goal of treating patients in an integrated approach and having the time to “document the care” that can translate into the proper Resource Use reimbursement for all of their efforts.  The answer many conclude is having the correct Electronic Health Record (EHR) that will collect data and provide a picture of the care. The truth is that no EHR can document something that is intuitive and a result of extensive clinical training.  Because no two patients are the same, the approach to patient care has to be individualized.  There is the mantra of the ACO (Accountable Care Organizations); that is, we should be able to see outcomes as data.

The Clinician sees the patient outcome not as data but as the ability of the patient to begin living a life after illness.  These two worlds are far apart and they may grow further apart when ICD-10-CM comes into being.  Does it really matter to the Clinician whether the patient was bitten by a parrot or a wren?  What matters is using all of the training, the experience of seeing many patients, the success with studies and interventions that make the patient well.

The purpose of this monogram is to point the way to bringing all of clinical side and the data side together in a way that supports the Integration of care!  At the moment these are seen as conflicting entities.  When Physicians/Clinicians round each day to see their patients they want to know how the patient is doing based on the diagnoses and the interventions.  Integration happens when all of the Clinical Team uses the same clinical documentation model, one in which each discipline focuses on the Patients specific problem list and whose notes reflect what has been done to improve those conditions.  Over the years “Nursing has insisted on its own documentation systems” as other professionals have. While there are discipline specific views of patients, Integration means bringing together each of the disciplines’ views of the patient into one picture that answers the question, “Is my patient better today; if not why not?”  Before the Electronic Health Record the best documentation could be seen in the Intensive Care Units where every data item was recorded and then trended for the individual patient.  The Clinician could see a picture. The typical documentation on the normal inpatient floors was a compilation of lots of narrative without a clear picture drawn from the data.

Where do we go from here? In looking at Health Systems Management data for the previous 30 years and the many iterations of Coding, DRG’s, MS-DRGs, we have concluded that “Integration is only possible by changing behavior and internalizing the real meaning of patient focus.”  HSMN has also concluded that ICD-10-CM may be the very opportunity to begin training for Integration of documentation and patient care.  The reasons are not simple; our conclusion is based on looking at the logic of ICD-10-CM which demands that the Clinician use critical clinical thinking in the specificity demanded by ICD-10-CM.  In the specificity each discipline has an opportunity to be communicating specifics to the entire team about diagnosis, interventions and outcome.  On the basis of our research, and interviews with hundreds of Clinicians, HSMN has developed a program that has shown success, especially in large institutions.  The program requires no software and is not a black box, but rather a change in the Clinical Documentation Paradigm which creates a bridge between clinical thinking/decision making and articulation of the same in the clinical record.

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