November 26 , 2007

Stopping a Broken Record — Coping With Chart Deficiencies
By Annie Macios
For The Record
Vol. 19 No. 24 P. 12

In any field, there is always one part of the job that is less desirable than others. For most people, including medical personnel, paperwork usually doesn’t rank as the most exciting item on each day’s to-do list. Nevertheless, the completion of documentation is not only important but mandatory, with state and national standards holding facilities accountable and hospitals relying on chart completion to allow for efficient billing and payment for services rendered.

HIM personnel are charged with making certain that medical charts are complete. But for various reasons, a complete chart isn’t always what they find.

Donald French, senior vice president of healthcare research and development for Optio Software, says protection from lawsuits and improved billing are the two main reasons charts must be completed in a timely manner.

“You can’t code a chart until the documentation is complete, and if you can’t code, you can’t bill,” he says. Discharged not final billed (DNFB) is an important measure hospitals use to examine the time between discharge and when the bill is dropped. “Every day that they don’t bill may create a cash flow issue,” says French.

He also points out that a complete chart is important because if some element is missing in the documentation when legal action is taken, “you have a problem.” By establishing a deadline for chart completion, The Joint Commission or a state’s health department can ensure that the patient history of care is fully documented and signed off on by the practitioner in question within a reasonable time frame. This provides enhanced accuracy in a patient’s chart and risk avoidance on the part of the provider regarding the ability to respond to legal requests swiftly and accurately.

Technological Advances
Technology has played an important role in mitigating the problems associated with deficient medical charts. Implementation of electronic medical record (EMR) and imaging systems, as well as the use of delinquency management software at many facilities, has made a major difference in reducing the number of incomplete charts.

French notes that larger or metropolitan hospitals generally already have or are implementing EMRs, while smaller or rural hospitals are often still using paper records. “Although many larger hospitals use our technology, we focus on the smaller, rural hospitals because our subscription-based solutions enable them to take advantage of the same technology as the larger ones at a price they can afford,” he says.

Small Hospital, Big Success
Gonzales Memorial Hospital, a 35-bed facility in Gonzales, Tex., has adopted Optio’s electronic health record and deficiency management software during the last six months. Since the implementation, Leslie Janssen, RHIA, the facility’s HIM director, has observed improved workflow and document completion. She is pleased with the software’s autodelivery feature, enabling analysts to review a chart online and send a notification to the doctor regarding any deficiencies. It also allows hospitals to automatically deliver clinical information directly to a physician’s office in the preferred format without human interventions. Doctors can access the chart from home or their office and utilize the e-signature feature for prompt completion.

“The capability to fax a chart from your desk has also been great, too,” says Janssen. This feature saves time and energy because nurses no longer need to call for a record, and the process of pulling a chart, finding and faxing the information, and then replacing the chart is eliminated, according to Janssen.

She also says the ability to access a record from any part of the hospital with the Internet has improved workflow because it allows physicians to complete charts at a convenient time and place.

Although Gonzales Memorial Hospital is not governed by The Joint Commission, it is subject to the Texas Department of State Health Service’s strict delinquency standard. “They don’t want to see anything incomplete over 30 days,” says Janssen, adding that the health department can penalize the facility for even one delinquent chart. Because Gonzales Memorial is a smaller hospital, however, it has been successful in keeping delinquent charts under control.

For physicians having difficulty with the technology or who are habitually delinquent, the HIM staff provides one-on-one training. It has also developed a user’s packet for physicians who don’t regularly come to the hospital.

Midsized Facility
Riddle Memorial Hospital, a nearly 200-bed facility in Media, Pa., recently made the transition from an entirely paper process to a completely electronic process.

Paper medical records make it difficult to complete charts because only one person can view the chart at a time, though more than one physician may be assigned to correct deficiencies on the same chart.

“Often, when one physician had the record, another doctor would visit at the same time and need the record to complete their documentation,” says Kelly Henry, RHIT, CHP, Riddle’s HIM director. With the EMR, however, the chart completion process can be performed online where charts are available for all clinicians simultaneously.

Riddle Memorial’s deficiencies are assigned online, and chart analysis staff now perform deficiency analysis via electronic charts. Previously, there was a secondary process of verifying physician completion of deficiencies after their visit to the HIM department. If the physician missed a signature or other item, the record would have to be refiled to the incomplete area. With the EMR, that entire process has been eliminated, saving time and improving workflow.

Henry has found that doctors need to have records available at their convenience. “Often, staffing an HIM department 24/7 is just not available in our budgets. We often would have physicians who were on call want to visit HIM late at night to complete records,” she says. Electronic record completion makes the process close to ideal, allowing physicians to work remotely or from in-house locations other than the HIM department.

A Helping Hand
At Riddle Memorial, the practice of using physician liaisons—individuals assigned to assist doctors with record completion—has been a tremendous help. When the HIM staff learn of a new physician appointment, the physician liaison immediately arranges training for dictation, electronic record access, and e-signature. “The liaison concept has helped support our policy at Riddle Memorial that all documentation be completed electronically,” says Henry. The medical executive committee has supported and approved a policy to this effect, adding a level of support that Henry calls invaluable.

At Riddle Memorial, chart delinquency threshold standards are set by The Joint Commission and the Pennsylvania Department of Health, which is a stickler about record completion. “Although our record delinquency rate routinely is single digit, we have been cited previously by our [department of health] when it discovered a delinquent record,” says Henry. Generally, the rule governing Pennsylvania facilities states that medical records must be complete in 30 days. Even with the 30-day period, Henry says Riddle Memorial works toward eliminating any deficiencies.

Despite the technological advances that have led to improved processes, Henry says there are still some doctors who are routinely delinquent, a practice that can result in a suspension of admitting privileges. “We try hard to work with the medical staff to avoid this and realize completion of medical records is the last thing a busy physician wants to do. But it’s an important part of their job,” she says.

Henry notes that it’s helpful if doctors receive the oldest deficiencies in their electronic queue first—so much so that liaisons train physicians on how to sort the most vital records and how to reconcile the chart.

She also points out that monitoring the process is just as important as maintaining the everyday processes. “Even if we take our eyes off it over a holiday weekend, for example, we see our deficiency count begin to climb,” says Henry, who recommends consistently monitoring for deficiencies to ensure an efficient system.

Familiarizing all personnel with the EMR technology has helped Riddle’s HIM staff tackle chart deficiency problems with more ammunition. “Train as many HIM staff on the process,” says Henry. Even if they do most of their chart completion work remotely, physicians still visit HIM, where there are dedicated workstations and staff on hand to assist them.

On a Larger Scale
Beth A. Kost, RHIA, chief privacy officer and HIM executive director at Wellstar Health System in Marietta, Ga., has also recently experienced the benefits of changing from a paper environment to an imaging system that forces physicians to complete charts electronically.

While the experience has been positive, it wasn’t without its challenges. “We have an interesting mix of acceptance of the technology,” she says, based on a wide range of computer experience among physicians.

“We think of deficiencies from the top level because state agencies, The Joint Commission, etc, have strict standards,” she says. Staff must review records to make sure all the pieces are in place, and if records are found incomplete, physicians must complete them.

An important first step in Wellstar’s pursuit of complete charts was implementing electronic documentation in the emergency department (ED), where many important documentation requirements are already built in. “So it has become much easier with a ‘point-and-click’ template that provides physicians with the appropriate fields for completion, and there have been fewer deficiencies,” Kost says in regard to ED chart work.

The biggest challenge has been authenticating the records, according to Kost. “The hardest part is getting physicians to sign the record at the end,” she notes. However, because the number of deficiencies has significantly decreased, Wellstar Health System can now shift its focus from checking for deficiencies to acquiring an e-signature on the charts and improving documentation.

Kost has noticed that in implementing the systems over the last 12 months, something even more valuable has emerged. “As far as expanding opportunities beyond what the regulatory and accreditation agencies require us to do [in regard to managing deficiencies], we are also looking at focusing the time that’s now available toward making the clinical information in the charts more clear, concise, and specific,” she says. The process has evolved from HIM being “record police” to discussions with physicians regarding improving documentation and, in the end, enabling better patient care.

“With an imaging system where numerous people can see the documentation according to their role and responsibilities, being more specific in documentation improves patient care,” notes Kost.

Another benefit with the online system is that physicians can complete the charts at a convenient time and place. “They can do it from their office; they don’t need to be in the hospital,” says Kost.

Based on Georgia and Joint Commission standards, Wellstar Health System’s five hospitals can’t have 50% of their charts deficient for more than 30 days. “Our hospitals are far below that,” says Kost.

To enforce the standards, Wellstar had a suspension program for noncompliant physicians; however, the program came to a halt when the health system converted to the imaging system because workflow changed so dramatically, and Wellstar officials wanted to give physicians time to learn the system, according to Kost.

In planning the imaging system implementation, Kost wanted a better understanding of her physicians’ routines for completing charts, so she sat down with them and heard their perspectives. “I would have never understood as well,” she says, noting that she took into account their varied learning curves and work routines.

Getting Personal
Now, Wellstar Health System is monitoring which physicians are not using the system and providing appropriate assistance where needed. “We can run audit reports to see who needs help,” says Kost.

That help is provided by customer liaisons who personally speak with a delinquent or nonparticipatory physician and assist when necessary. One finding is that some doctors would view the record online but not always complete the chart. Whatever the situation, problems are dealt with professionally. “Almost all communication is done by phone, not a letter, to tell them if they have deficient charts,” says Kost. By taking a personal approach and enabling physicians to speak directly with a customer liaison, Kost has seen delinquency rates drop. “There are still some challenges, and a handful of physicians are still struggling,” she says, “but it’s been a huge success so far.”

Henry agrees: “On the whole, electronic record management brings a new set of challenges, but we love it and would never wish to take it away.”

— Annie Macios is a freelance medical writer based in Doylestown, Pa.