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 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 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.
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 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 above standard documentation practices.
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.