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LESLIE: Listening to a recent audio seminar, Documentation 101 for the 21st Century, presented by the OneBeacon Professional Partners (www.onebeaconpro.com), I was struck by how serious the financial and legal ramifications are when the quality of medical record documentation is poor.
PATTY: The financial impact of documentation will likely increase as the health care industry faces more pressure to reduce costs, expand the use of EHRs, and comply with various other regulations and trends that are dependent upon clinical information.
LESLIE: Despite its importance, the difficulty of achieving accurate, complete, timely and authenticated documentation is greater than ever. As I listened to the speakers I realized that managing the limitations of hybrid records, accelerating the implementation of EHR technology that is still far from perfect, and preparing to respond to the not so distant drumbeat of health care reform, are challenges that will require steadfast leadership and expertise from HIM professionals for years to come.
PATTY: Leslie, I think I hear a call to action in your voice.
LESLIE: It is a call to action! The importance of an individual's clinical information has been recognized by professional groups, the legal system, and the public since the early 1900s when the first voluntary accreditation standards stated one patient to a bed and one record to a patient-setting the stage for the enactment of laws, standards and rules governing the content and processes relevant to patient records. Since its inception in the 1920s our profession has been in the forefront of creating the best practices in managing patient information. We don't intend to stop now.
PATTY: You are absolutely right! The fundamentals of good documentation and record management apply regardless of the medium, be it paper, electronic or hybrid.
LESLIE: You may recall a book I co-authored back in the late 1970s called the Record that Defends Its Friends. It was a simple, straightforward guide to proper medical record documentation that would serve the patient, the care givers and the facility well. While those fundamentals are still relevant, new challenges in our highly stressed health care industry require our attention as experts in record content and data quality. We need to take a fresh look at clinical documentation in the electronic world and collaborate with providers and informatics and information technology professionals to establish standards that will serve as the new fundamentals for future generations.
PATTY: HIM professionals have an opportunity to do just that as part of the Recovery Audit Contractor (RAC) program. Auditors contracted by the Centers for Medicare and Medicaid Services (CMS) are looking for patterns of documentation and coding that do not support payments already made on claims. They can look at records of patients discharged as far back as Oct. 1, 2007. If the contractors find either coding errors or a lack of documentation substantiating medical necessity, the payment will be reduced and money taken back. The stakes are very high for health care providers and organizations. During the demonstration project conducted in only three states, CMS realized close to a billion dollars.
LESLIE: Reporting requirements also present documentation challenges according to one of the speakers at the seminar, Kathy Johnson, director of coding services at Care Communications Inc. One example is the CMS requirement for reporting conditions "present on admission (POA)." Distinguishing those conditions from hospital acquired conditions sounds straight forward but actually there are gray areas. For example, consider a newborn with an umbilical cord wrapped around its neck; was the condition present when the mother was admitted or did it happen after admission. Though circumstances are not always clear, if the hospital reports "unknown" too often, that can bring additional scrutiny. Financial penalties for hospital acquired conditions can be costly, so a complete and accurate record is critical in these cases.
PATTY: Of course it isn't only reimbursement and reporting issues that drive the need for good quality documentation. The electronic medical record must meet the business record rule, making it discoverable and admissible in a court of law. Failure to maintain the legal integrity of a record can result in a failure to support a provider in the event of a malpractice claim, or a patient in the event of a personal injury or worker compensation case. Even worse, according to Fay A. Rozovsky, JD, MPH of The Rozovsky Group, Inc./RMS, studies of closed claims over the past 200 years in the U.S. and Canada have revealed a common thread: there is a breakdown in written and verbal communication.
LESLIE: As Fay said, "from the IOM reports through multiple studies over the years to today's American Recovery and Reinvestment Act of 2009 (ARRA), the message is clear: good clinical documentation practices are essential for achieving patient safety."
PATTY: Expectations for EHRs are high. The hope is that they will produce more complete and accurate documentation and that should spell good news for quality care, thus fewer malpractice suits, as well as a more accurate record to be used in case of litigation.
LESLIE: While that is the hope, we should also realize that there are aspects of EHRs that could create new ways for lawyers to use clinical information in malpractice litigation. For example they could issue a subpoena for aggregate data from a health care facility's EHR system, making it possible to explicitly compare a record in a malpractice case to the standard of care across similar cases in the organization, or even to other organizations in the region. Also, in legal cases a timeline is often crucial to the outcome of a case. With EHRs, attorneys will have access to more accurate information on date and time of entries, whereas in paper records we know that such information is often missing or may be inaccurate.
PATTY: At this point in time just getting a good representation of an individual record printed from an EHR can present problems. Most EHR systems were not created to produce printed copies of records, and the copies they do produce are often cumbersome and difficult to use to get a complete picture of what transpired during the course of treatment.
LESLIE: The problem of the complete story is being addressed by the Health Story Project, which was featured in the April 2009 issue of ADVANCE. The Health Story Project, an alliance of health care vendors, providers and associations pooled resources in a rapid-development initiative called "CDA4CDT" (Clinical Document Architecture for Common Data Types) to produce data standards for the flow of information between common types of health care documents and EHRs.
PATTY: The founders of The Health Story Project share a vision that all of the clinical information required for good patient care, administration, reporting and research will be readily available electronically, including information from narrative documents. EHRs that have only structured encoded clinical data result in gaps in the patient's complete health story. The standards they are creating will bridge the gap between the structured data and narrative documents. These standards will be key to creating a complete, meaningful picture of a patient's health care experience with a provider. (More information on The Health Story Project can be found at www.healthstory.com/index.html.)
LESLIE: As the uses of clinical documentation continue to expand, HIM professionals will play an important role in establishing new best practices. The third speaker at the seminar, Gwen Hughes, director of HIM consulting services at Care Communications, suggested that HIM professionals need to stay on top of the risk management issues that emerge with the widespread adoption of EHRs.
PATTY: What does that look like Leslie?
LESLIE: First, HIM professionals must have a strong presence on the teams that select, design and implement EHRs. Second, they have to continuously network with colleagues to share and educate on documentation related experiences. Gwen suggests that HIM professionals work with their organizations' risk managers to include medical record documentation as part of their risk management assessments and co-lead actions to maximize the return on documentation investment and minimize risk.
PATTY: This is the most crucial time in the history of the HIM profession to demonstrate expertise in documentation and record content management.
LESLIE: It is perhaps our single most important contribution to health care reform. The stakes are high. Now is the time to make sure HIM is on the health care reform train. It has definitely left the station.
Leslie Ann Fox is chief executive officer and Patty T. Sheridan is president, Care Communications Inc., Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or ptsheridan@care-communications.com.
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