March 16, 2009

Take Documentation Out of the Dark
By Selena Chavis
For The Record
Vol. 21 No. 6 P. 10

Concurrent documentation can help solve problems on the fly, leading to improved care and increased efficiencies.

Getting physicians to improve their documentation has long been a goal of most HIM departments. Logically, it comes down to commonsense documentation. If physicians can be alerted to problems quickly, while a patient is still in their care, then the chances of correcting or improving documentation quality are greatly enhanced.

That’s one reason why many clinical documentation improvement programs are moving toward a concurrent approach, which essentially means that documentation is clarified “while a patient is in a doctor’s face instead of weeks later,” says Marie Morin, RN, MSN, CCS, a senior consultant with Minnesota-based Ingenix consulting group. “It allows us to clarify documentation in a timely manner.”

Healthcare organizations that have recognized the need for allocating resources to these types of programs are finding that they have tangible effects on improving errors, patient outcomes, and compliance. “We’ve had a concurrent documentation program in place since July 2008,” says Rebecca Hall, RHIT, HIS, coding manager for Missouri-based Heartland Regional Medical Center. “Our facility has seen a great improvement in our documentation with better capture of the severity and risk of mortality of the patients that are admitted.”

With those improvements also come better coding and a more efficient revenue stream, notes Tammy Love, RHIA, CCS, director of HIM coding at the University of Arkansas for Medical Sciences, which rolled out its program in early 2007. Since then, the facility has been able to bring its discharged not final billed down to four days. “It has definitely improved, and we have maintained it as our goal,” she says, adding that the department typically receives an 80% response rate from physicians when following up on documentation issues.

While the concept of concurrent documentation has been around for years, Garri Garrison, RN, CPUR, CPC, CMC, director of acute care services with 3M Health Information Services, notes that there is a renewed focus on the effectiveness of these programs, especially in light of more intense scrutiny over medication and documentation errors, present on admission (POA), diagnosis-related groups (DRGs), and recovery audit contractor (RAC) audits. She points out that with the increased need for specification, concurrent documentation seems to be a natural course for most facilities.

“I would say that about 98% of documentation improvement is concurrent,” Garrison says, noting that sometimes it’s more difficult for smaller healthcare organizations to allocate the resources for these programs. “Most hospitals see an improvement of case mix of 2% to 4%. That can be a big number. … It can equate to millions of dollars in some facilities.”

Need for Specificity
All roads lead to the need for greater detail and more specificity from physicians, Morin says, adding that concurrent documentation lends itself to improving a facility’s ability to accurately code the severity of illness for DRGs and capturing needed data to support POA claims.

“The quality report is so much better because we are capturing more diagnoses,” Love says. “It’s painting the picture of severity of illness better.”

Garrison points to a typical example in which a patient comes to the emergency department (ED) with shortness of breath, fever, and lung issues. The physician initiates an admit order for congestive heart failure and also orders IV antibiotics.

With a concurrent documentation program in play, a chart audit the next day would reveal that the physician had not documented enough information to capture all of the patient’s conditions upon admission. Specifically, the patient also presented with pneumonia.

“In this case, the ED physician takes care of the immediate need but didn’t really say anything about the second condition,” says Garrison, who adds that POA is driven by documentation completed when a patient presents for admission. “It’s really about working hand in hand with your physician. It goes back to looking at those conditions and determining if there is enough information there to show it.”

In another case, documentation from two separate specialty physicians in a chart may conflict. “The one I see all the time involves TIA [transient ischemic attack] and stroke,” Garrison says. “One [physician] says it’s a stroke, and one says it’s not.” The information would need to be clarified quickly because the two diagnoses are coded under two separate DRGs.

“When we do chart audits, we find that severity of illness is understated 8% to 15% of the time,” Garrison says. “Mortality is understated 15% to 25% of the time.”

When documentation issues are captured and corrected in a timely manner, common sense reveals that overall documentation will be better, Morin says, emphasizing that facilities will automatically be better positioned for a RAC audit if they have a documentation improvement program in place.

“Concurrent documentation allows us to clarify documentation … so when we submit a record to RAC, we have a solid foundation,” she explains. “We don’t want to feel like we have stretched anything. … We want it to be an honest portrayal.”

Professionals agree that a combination of current needs to address documentation improvement alongside an industrywide movement to eliminate documentation errors and the oncoming ICD-10 implementation only enhances the justification to allocate resources for concurrent programs.

“Concurrent documentation will help facilitate ICD-10 in that we are going to need to be much more specific,” Morin says. “It works in synergy with the needs that ICD-10 will present.”

Garrison points out that there are several competencies that will have to be addressed as facilities move toward ICD-10 and that concurrent documentation programs align well with those needs. Specifically, facilities will have to train physicians to understand the greater specificity needs of the coding system; coders will need to understand the foundational elements required for the new codes; and there will have to be a mechanism in place to ensure that everything lines up.           

Choosing the Best Model
Industry leaders say there are many ways to approach establishing a concurrent documentation program, and there are many models that work. But the key is finding the model that fits best into the workflow of a particular facility.

In her experience, Garrison has witnessed three models most frequently implemented: a stand-alone team that answers to coding, a team integrated into the coding department, and a designated team that is integrated into case management.

“I’ve implemented all three models, and all can be successful,” she explains, adding that the choice often depends on workload.

In the case of a large hospital with hefty discharge planning needs, a stand-alone team often works best. Smaller hospitals are in a better position to accommodate an integrated approach and often have to consider this route due to the availability of fewer resources.

“We chose to keep it all in HIM,” Love says of the situation at the University of Arkansas Medical Center, a 333-bed teaching hospital employing 1,100 physicians. “We felt like HIM was the best and most knowledgeable, but it would require adding resources to the department.”

At Ochsner Health System, which encompasses seven hospitals and more than 35 health centers throughout southeast Louisiana, the concurrent documentation program was initially incorporated into the daily responsibilities of the case management department.

“Unfortunately, this model didn’t work well for our facility, as it was too difficult for the case managers to add another responsibility to their daily tasks,” says Wendy Clesi, RN, director of documentation excellence. “After about two years, we transitioned the program to a focused review model. Our program has been in place for four years. The benefits have been tremendous, both financially and from a quality perspective. The overall impact has been extremely positive, with outcomes that have far exceeded our expectations.”

Morin notes that keeping documentation review programs outside of case management is typically a better approach when resources are available to allocate specific staff to the task. “Case managers are continually in the records now,” she explains. “What we find is best is to keep clinical documentation specialists and case management specialists separate.”

Some facilities have also tried concurrent coding programs, but Garrison notes that many have abandoned this process. “The reality is that with concurrent coding, there are so many pieces of the record that are not in the chart on the day of discharge,” she notes. “Often, coding has to be redone.”

Nevertheless, Love says, the University of Arkansas Medical Center has made concurrent coding work under its system where the process is already integrated into HIM.

In most facilities, the daily activity of designated review staff involves auditing charts from the previous day, collaborating with physicians for feedback when issues arise, and following up on issues from previous days.

“After an initial review, you set your review date,” Garrison explains. “Most often, you see patients every couple of days, but some you have to review daily.”

The system at Heartland Regional Medical Center involves the use of two documentation specialists, who visit the patient floors daily to review charts. “These documentation specialists will meet with physicians face to face to discuss questions or missing information in the patient’s record,” Hall says. “The documentation specialists also write and send physician queries via an electronic system. The program has been such a great success that we are currently seeking two more documentation specialists.”

The Physician Factor
While the benefits to these programs were easily accepted by the Ochsner Health System administration, Clesi recalls that the big question was, “How did we get the physicians on board?”

“This seems to be the biggest challenge with most programs,” she points out. “Physicians and documentation specialists don’t generally speak the same language when it comes to inpatient coding, hospital billing, and profiling outcomes. The physician’s responsibility is to care for the patient, not to keep up with the ever-changing regulations or the health system’s business concerns.”

Clesi suggests the best way to get physicians on board is to communicate the program’s purpose and benefits in a way they understand and appreciate.

“Working with physicians requires excellent communication skills, knowledge about current clinical practice, coding rules and regulations, and the ability to interpret and communicate data outcomes,” she says. “Physicians do not like it when they are taken away from the patient’s bedside to listen to someone who is not knowledgeable or to hear information they do not understand.”

The organization recognized that without physician buy-in, the program would not stand a chance. A series of introductory presentations was provided to physician groups across the facility through the company’s consulting group. This process allowed the physicians to hear the information from an outside source.

In addition to the initial sessions, Ochsner is now presenting the program to all new physicians during their first week of orientation, as well as facilitating an annual resident education session.

Garrison suggests that organizations also consider how they present the program’s benefits, emphasizing that physicians respond better to benefits associated to quality of care than revenue cycle. “If you have done physician training about mortality improvements, you’ll get physicians on board,” she says. “If you make it about money, it’s another story.”

Framing it in a way that has direct benefits to the physician is also a key to success, Hall says, pointing out that physician education continues to be the greatest challenge at Heartland Regional Medical Center. “Before our concurrent documentation review program went live, we offered three weeks of on-campus training for all physicians,” she says, adding that a third-party vendor led the training and explained how the documentation reflects on the organization’s public image—especially on performance Web sites such as Healthgrades.com.

Morin points out that it’s also crucial to have a lead physician who is taking up the charge. “I can’t stress how important physician advisers are to this process,” she says. “Physicians are much more responsive to physicians. We generally ask a facility to identify someone who the other physicians respect. They have to have respect to be functional in the role.”

In the end, it’s all about getting a complete chart that accurately reflects the quality of care given to a patient.

— 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.