Documentation Practice Assessment
Documentation assessment is a major tool that impacts Revenue, Quality, Risk and Outcomes. At a very basic level the documentation practices of the clinical staff is very much at the center of whether a Practice, clinic, or hospital owned group is going to be successful.
So much emphasis is being directed to the coming ICD-10 Scenario, the one the AMA would like to postpone forever. However, the codes are the interpretation of the documentation into a language that is submitted for aggregation by CMS and payment by third party payers.
The specificity of the codes is the only thing that is different. The bare essentials of a medical exam, decision making, and important notations on study results leading to the decision making remain critically important.
So if your documentation is not pristine in ICD-9 it is going to be harder to be successful under the new scenario. We suggest the following:
- Pull a sample of records for practitioners in the practice or clinic or hospital setting and use the deconstruction method to determine what is and what is not in the clinical documentation.
- Reconstruct the cases and review with the medical staff so that the cases become a template for them to learn good documentation practices.
- Often when you find a Champion, someone who does it well, it is always good to have that person be the representative for clear, concise and comprehensive clinical documentation.
- Use the “Case Conference” opportunity to mention ICD-10 with one tiny example based on the cases you have deconstructed. Take baby steps with this because the truth is ICD-10 will be implemented.
For over 25 years, HSMN has worked with physicians in every imaginable setting on the common sense approach to good documentation practices.
EMR
HSMN has worked with practices in every setting to assess what their electronic needs are. Practices often make the mistake of looking at products and then trying to match their practice to a product. In our experience, you don’t yield the best result that way. The way we go about our practice is to understand the practice values, culture and objectives. Is it a growing practice? What is the discipline? Is it a practice in which a patient may see more than one of the clinicians in the practice? Is it one in which there are several offices to which the patient can go for treatment?
On the diagnostic and treatment side, we know the kind of information that is of most value. Is any of this to be joined to the demographic and billing information? In considering all of these issues, the principals of the practice must establish a baseline for what the practice needs and a wish list for what it would like to have.
With those criteria in mind, the principals can begin looking at vendors. In this case you are matching your practice criteria to the specifications of a vendor to see if they coincide, and of course due diligence is important in understanding the vendor track record and quality of the service.
HSMN has won several awards for its work in Practice situations where criteria had to be established based on Practice values and Patient Care. At Johns Hopkins, our firm developed the criteria and specs for a system that was not yet available. With this criteria and Johns Hopkins’ own resources, they built one of the first Ambulatory (practice) electronic records for which it won the Smithsonian Award.
In most of the literature and articles written by physicians, it is clear that an Electronic Medical Record is costly and time consuming. What most practitioners want is time. If you can save a physician time, you have given them the most valuable resource they have. But if you can’t, don’t bother.
We often see vendors and other marketers with blaring advertising that says, “we can help you to determineMeaningful Use,” which in the new Health care law allows for Medicare payments at a higher level. In all honesty, those payments never equal the amount of time that must be invested in acquiring a system. So it is important to start with your practice. What does it need? What will save you time.
HSMN recently reviewed an Oncology Practice in which Medical Records were difficult to find and often lost. The reason was fairly simple; poor management of the manual system and an overwhelming need to have multiple clinicians (mostly the infusion nurses and nurse practitioners) also have access to the records along with the principal physician. In this practice we recommended a multiple phase correction program starting with a Manual process and then moving forward to an Electronic Record that meets the practice standards.
We often find Clinicians going to their annual meetings and coming back with wonderful news about EMR’s. We say look at your practice first and foremost to provide you with the insight you need to decide on a product or vendor.
Medical Records/HIMS
All health care providers must maintain a health information record that documents clinical care provided to their patients. The healthcare record, whether it is an electronic health record (EHR), paper or other format serves multiple purposes. In addition to documenting and supporting clinical care, health care records must also be maintained for business, compliance and risk management purposes. Regardless of whether the media used to create and store health records is electronic, paper or other, organizations should define one set of health information that meets the legal, business and regulatory needs of the organization.
As the custodian of the record, the Health Information Management (HIM) department is responsible for maintaining the record in a manner that complies with all applicable legal rules and regulations, accreditation standards, organizational policies and procedures, and clinical practice standards. HIMS therefore should play an active role in identifying the content of the organization’s health record as well as the standards for maintaining the integrity of that content. HSMN, with over 25 years’ experience in clinical documentation standardization and policy creation and implementation, has developed a methodology for helping providers in all settings define a healthcare record that meets the needs of the organization. As providers shift to maintaining health information in an electronic format, our in depth experience will help the organization use certified EHR technology in in Meaningful Use.
Quality Assurance and Utilization Review
HSMN has helped to create and reorganize both Utilization Management and Quality Assurance Programs. We very much agree with the Joint Commission on the Accreditation of Health Care Organizations that Quality must be demonstrable not just described. Quality must be internalized not just overseen by the QA Department. No provider organization whether it be a tiny hospital or group practice should exist without a Quality Assurance Program. A true understanding means that a Partner coming into a practice must understand that Quality is the means by which your health care delivery product becomes known and marketable. HSMN has specialized in developing sustainable programs that become part of the cultural fabric of the organization. In setting up such a program, much depends on the individuals within a practice who are willing to monitor themselves and the quality of their own work. Self monitoring is the strongest form of Quality Assurance. There must be a way in each health care organization especially in Physician practices that one can demonstrate Quality. Often it is in the numbers, but more importantly it is in the patients who return and recommend the group to others. The ability to identify problems early on is the sign of a terrific program. Auto Manufacturers put sensors in cars for literally every function and as health care providers, we must create our own sensors and work with peers to identify and fix the problems. HSMN can help launch a sustainable program.