Medical Record Organization & Management

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 another 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. Regardless of whether the media used to create and store health records, 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 Medical Record 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. Medical Records should therefore 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 adhering to regulations and standards. We also assist organizations in establishing their electronic health record selection criteria  and specifications.

Documentation Practices

Documentation assessment is the only tool that has an impact on 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 of the documentation into a language that is submitted for aggregation by CMS and payment by third party payors. 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 above standard documentation practices.

Quality Measures

Incentive Programs

The Centers for Medicare and Medicaid (CMS) have developed several quality initiatives and programs to provide information on the quality of care in the physician office setting.

• The Physician Quality Reporting System formerly known as The Physician Quality Reporting Initiative (PQRI) provides an incentive payment to physician practices who satisfactorily report data on quality measures.
• The EHR Incentive Program “Meaningful Use” provides a financial incentive for the “meaningful use” of certified EHR technology to achieve health and efficiency goals.
• The Electronic Prescribing (eRx) Incentive Program is a reporting program that uses a combination of incentive payments and payment adjustments to encourage electronic prescribing by eligible professionals.

From the Medicare Learning Network – March 2011

“Dr. Smith submitted $50,000 in allowed charges to Medicare during calendar year 2011. During that same period, the doctor met all of the eligibility criteria to participate in the Medicaid EHR Incentive Program. In 2011, Dr. Smith satisfactorily reported data on Physician Quality Reporting System measures and qualified for a Physician Quality Reporting System incentive payment. Dr. Smith also qualified to earn an eRx incentive payment because in addition to meeting the criteria for being a successful e-prescriber, more than 10% of the doctor’s MPFS allowed charges were composed of services included in the eRx measure’s denominator.”

How much in incentive payments will Dr. Smith receive for 2011?

PQRS

PQRS, formerly PQRI, was initially implemented in 2007 based on the desire of CMS to ultimately support new payment systems that provide more financial resources toward improved quality care, rather than simply paying based on the volume of services. Since 2007, they have incentivized providers to report data on quality measures for covered professional services. In 2011, the incentive earned by participating providers equaled 1% of charges for accurately reporting selected quality measures. CMS will continue incentivizing physicians to participate in PQRS through 2014.

However, beginning in 2015, providers who do not satisfactorily report measures under the PQRS will be subject to a payment adjustment equal to 1.5% of their MPFS charges!

Meaningful Use

What is meaningful use? Per CMS, meaningful use simply means that providers have to show that they are using certified EHR technology in ways that can be measured significantly in both quantity and quality.

Stage 1 has already been implemented, setting the baseline for electronic data capture and information sharing.

Stage 2 (expected to be implemented in 2013) and Stage 3 (expected to be implemented in 2015) will continue to expand on this baseline and be developed through future rule making. In Stage 2, what will your EMR be expected to do?

According to a proposed rule, physicians would need to use their EMRs to meet 20 functionality objectives at minimum levels to earn bonuses and avoid penalties. Functionality objectives include:

• CPOE
• E-Prescribe
• Recording patient demographics
  • chart vital signs
  • smoking status
• Using clinical decision support
• Incorporating clinical lab results into EMR
• Generating specified patient lists
• Patient Interaction
  • Patient reminders
  • Patient portal access
  • Patient messaging
  • Providing clinical information
  • Providing education resources
• Using medication reconciliation
• Transmitting electronic data for various purposes
• Ensuring EMR privacy and security
• Accessing diagnostic imaging
• Recording patient family histories as structured data
• Having the ability to report specified cases to registries

Source: CMS

Again, beginning in 2015, providers who are not successfully demonstrating meaningful use (Medicare only) will be subject to payment adjustments of their MPFS charges!

E-Prescribing

Approximately 530,000 preventable drug related injuries occur just among Medicare recipients in outpatient clinics alone each year. A provider’s ability to electronically send accurate, error-free and understandable prescriptions directly to a pharmacy from the point-of-care is an important element in improving the quality of patient care.
The eRx Incentive Program which began in 2009, provides incentive payments to practices who successfully e-prescribe for covered services to Medicare Part B beneficiaries.

Beginning in 2012, eligible professionals who are not successfully e-prescribing and do not qualify for a hardship exception will be subject to a 1% adjustment of their MPFS allowed charges.

Earlier in this article it was shown that $22,250 in incentives can be earned by a provider who has annual charges of only $50,000. Those providers not participating in these quality programs in 2015 can anticipate a significant adjustment in payments on allowed charges. Providers cannot afford not “to get with the program.”

HSMN has in-depth experience with helping providers transition to electronic solutions and in abstracting quality data elements from clinical documentation. We can help your practice find solutions to the problems currently preventing you from participating in these quality incentive programs.

The EMR Decision Trail

The decision to have an EMR should be based on the way you practice and what you think the EMR can help you accomplish. Too often practices fall for all the bells and whistles and then end up having to match their practice to a product. That’s not the way to go. It is essential for you to think about how you practice and all your workflows, then for each important step in your clinical management, list it as a specification.

Let’s say you want to track all of your patients who have high blood pressure to monitor their outcomes, you need data. However, if using an EMR doesn’t save you time, forget it. 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. The real benefit of the EMR is the retrieval of information from a central and interactive hub, with an efficient use of time.

When you are looking at various systems, see which one fits the specs you have written. Think about the ease with which you need to communicate with others, especially the hospital system to which you admit. What are your reporting needs? Will the reports help you improve your clinical outcomes, take advantage of quality initiative programs and even reveal new stories about your revenue streams?

You must be able to “slice and dice” your data in various ways to hone in on improvement opportunities; this may include just a simple view of an account level transaction, but can you get there directly from the high level reports being produced? It is vital to the livelihood of your practice to see the both the areal and the microscopic views.

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 wasn’t available.  With its own resources, Johns Hopkins built one of the first Ambulatory (practice) electronic records for which it won the Smithsonian Award.

We have also assisted many practices in conducting a comprehensive analysis post their EMR implementation to ensure that everything works the way they need it to. Whether you are using paper charts or a system with too many limitations, we can help orient you in the direction of success.