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A dangerous virus has infiltrated hospitals. It endangers physicians as well as patients.  It is much more virulent today than it was a generation ago.  It affects almost any type of patient but inpatients are particularly at risk.

The busy physicians seem to be most susceptible to the problems it creates.  It is quite costly for hospitals that have to care for the sick, regardless of payment.  A tremendous amount of money and education is being spent to counteract the ravages.  Patient safety is at risk when providers fail to address the problem……..

The name is often misunderstood however “Complacency” will do.

All physicians are taught that to care for a patient is a serious responsibility.  It seems that many doctors have little time or understanding for the myriad of conditions that they may not treat directly that they take responsibility for these when procedures are done.  Our mentors would likely frown at the suggestion that “we don’t really care” about co-morbidities that directly or indirectly can compromise the success of our care.

Ponder the impact of steroids, diabetes, peptic ulcer disease, chronic kidney disease, congestive heart failure, anticoagulation on an otherwise straightforward procedure.  The assumption that an army of specialists can improve the “quality” of specific documentation is faulty as most conditions change in the face of unrelated but important co-morbidities.

Your reputation is damaged when these conditions are not specifically counted and your hospital can suffer with you. Physicians who don’t believe will eventually be surprised to find out where they fall on the list.

It is impossible to understate the movement occurring within organized medicine. One such example is the use of “protocols” that many disdain.

Unfortunately, quality assessment tools are increasingly used retrospectively demonstrate gaps between actual care and commonly accepted practice. While it is true that the use of protocols can rob the bedside physician of the personal touch to treatments, these protocols help to insure that the delivery plan falls within acceptable guidelines. The goal should be to eliminate all errors –real or perceived– that occur within American hospitals. Each medical staff will have the opportunity to adopt or reject a wide variety of care plans including but not limited to DVT prophylaxis, stroke, MI, antibiotic delivery, decubitus avoidance, fall avoidance, etc…. We seem to be awash with the concept.

Most protocols provide exclusion criterion to be used by physicians and hospitals who choose not to follow guidelines. Care must be taken to document exactly why the deviation is indicated. Anecdotal evidence will not, and should not, be tolerated as a reason since we are judged (literally) in the courts based on the best available scientific facts.

There is no question that the bedside physician is best able to treat a patient — the requirements today for more complete documentation help to protect individuals from the retrospective critics.

Take advantage of electronic tools to assist with the demonstration of patient co-morbidities and be rewarded by silencing armchair critics.

According to the World Health Organization, 1 in 10 medical encounters result in a medical “error”, 1 in 300 of these medical “error” result in death while only 1 in 10 million airplane events result in death.

This is highly offensive to physicians because it does not account for patient illness severity.

This helps make the point that we physicians should increase the data about patient morbidity (my premise).  At least when “bad” things happen there is an understanding about why. The institution of protocols is an effort to move best practice examples to the mainstream. Proving a “standard of care” was followed by protocol protects the hospital and physician from criticism while “robbing” individualized treatment decisions from managing doctors. It presents a double edged sword as the physician is best able to make on-the-spot decisions about a care plan that may not follow “protocol”.  The weakness is often the lack of documentation as to why the decision was made. This includes all co-morbid conditions that can help to demonstrate this indirectly.

The sooner physicians and hospitals understand this responsibility to continually enhance medical diagnosis, the sooner they will be demanding health information exchanges rather than laboriously queuing them up among other projects to meet “Meaningful Use”.

It never occurred to me before to be concerned about “specificity of documentation”.  I was busy and it seemed not to matter on the surface.

This concept was not taught in medical school or residency. I would never devote the time to learn how to do it. What changed?

•   – Perhaps it was the criticism of U.S. medicine that we consider to be the best in the world.
•   – Perhaps it was the alleged “98k medical errors”.
•   – Perhaps it was the perpetual reimbursement decline for physicians.
•   – Perhaps it was the reality that EVERY physician is likely to be a lawsuit target in their career.
•   – Perhaps I realized my practice was no longer “private”; numerous internet sites showed my “quality”.
•   + Likely it was an amalgam of all of the above.

It seems now that any physician who doesn’t give a rip about the specifics of their work has lost their collective mind. It brings up a line from my favorite literary work ……….

Who is John Galt?

Now it seems to be easier to play the “game” that payors have instituted over the last 30 years; especially the dominant payor who reimburses the lowest rates and has the highest rate of charge rejection: Medicare. Electronic solutions exist to make information transfer more efficient. The objective is to COMPLETELY describe your patient on EVERY pass through a medical encounter to get credit for managing their problems. Physicians who believe they escape liability by ignoring co-morbidities are sorely mistaken.

Simply imagine a plaintiff’s lawyer asking, “So Dr X …….you were not aware your patient had a history of kidney transplantation”?

The DRG system which increases hospital reimbursement for documentation specificity also paints the picture of the patient for whom the physician cared. Physicians who dare not to participate will lose ground versus the world of their peers.

I frequently hear from physicians “What’s in it for me”?  My response now is “Everything you trained for”:  Quality, Reputation, Reimbursement, and Respect. Documentation improvement is one change whose benefits have become crystal clear to me…

Diagnosis Related Groups were originally implemented in New Jersey as a pilot program to replace the cost based reimbursement.  The DRG system has evolved to stratify the payments from Medicare to hospitals based on the severity of illness documented by physicians.

The nominal system contained 467 categories and minor additions have occurred since the inception in 1982. Today, assignment within a given category (Appendicitis for example) is based on the description of severity documented by the managing physicians. Level 1 (MS-DRG 343) may be appendicitis without complications or comorbidities while Level 3 (MS-DRG 341) would include the description of ruptured appendicitis or simple appendicitis in a patient with an acute myocardial infarction. For any given hospitalization adding more “CC” or “MCC” codes do not drive higher reimbursement.  HOWEVER, these diagnoses do help paint a vivid picture of the complexity of the patient.  As these recorded conditions are described and retained, this will insure proper reimbursement during subsequent admissions once the Appendicitis emergency has passed.

There is ever increasing pressure to improve documentation for accountability and to gain reimbursements for the skills consumed and the risks taken by both physicians and hospitals.  These improvements are going to put a faster drain on the finite funds allocated for Medicare reimbursement in the near term.  These competing pressures will encourage CMS to change again this basic system to a more specific system with many more levels or a “sliding scale” of reimbursement.  MS-DRGs have a “Relative Weight” of complexity that is so assignment by the expected resource consumption and patient risk associated with the procedures and complicating diagnoses.  It is quite logical, that a prioritized Relative Weight will soon be assigned to every diagnosis, primary and secondary, such that an algorithm to calculate reimbursement could be introduced in our emerging era of CMS cost management.  It would be good practice for all medical practitioners to gather all possible information now so that this changeover would not be a shock, but rather a benefit.

Physicians should be ready to accept lower rates of reimbursement if they do not engage the documentation improvement requirements. All physicians are encouraged to learn now to avoid increasing difficulties anticipated with ICD-10.

We grew up in a healthcare environment where every treatment was “trusted” and assumed to be up-to-standard because of the educational investment required to practice medicine.

This certainly has not disappeared today.  However, retrospective review via the internet of physician and hospital results is a normally accepted practice by patients, medical societies, third party payers and the public at large. Transparency as a concept is a noble goal.  Full understanding of results is much more difficult.

Documentation of physicians’ medical events has never been as important as it is now.  We are searching for ways to sustain American healthcare without severe cuts. Each physician should understand that by increasing data capture we are actually increasing the understanding about how hard it is to achieve the “expected perfection”. Documentation amongst our nursing and medical colleagues increases the trust that can be lost when events are unilaterally recorded. Every member of the care team should ideally be on the same page. Increasingly we will be measured and each of us has a responsibility to improve documentation if we want to survive the scrutiny by the growing electronic surveillance.

Many colleagues will disagree citing that it has nothing to do with actual care.  However, the people paying the bills are increasingly demanding this “behavioral change”.

The physician who performs ANY procedure has a responsibility to provide instructions to caretakers, both family and healthcare workers.

In an inpatient environment these instructions are often a series of post-operative orders.  There is also a duty to describe the expectations over the postoperative days, weeks and even months following the procedure.  Obviously, some physicians are better at communication than others but this duty cannot be satisfactorily handled solely by nurses at discharge.  A written, legible set of instructions that are given to the family at discharge are ideal to record and convey information. This can alleviate frustration experienced by the family and reduce the phone calls generated to the doctor or their office after discharge. Although every possible question cannot be covered, this extension of the communication chain enhances safety and satisfaction with the care provided.

Too often our industry has accepted less than optimal practices as the norm and efforts to improve are well received by all involved.  Summary sheets with a laundry list of check boxes are intended to prod our memories on items to cover with nurses and family, but they are not personalized on the procedures performed and the patient’s condition.  Electronic solutions should be tailored to the physician to provide information at the time of procedures to convey precise instructions for what I or other physicians know about specific cases and patients.  This would be an ideal time saver to produce consistent, legible reports to cover almost anything.

Healthcare is under attack for our lack of detail and all attention to this matter will help.

I hear periodically that physicians are concerned or advised that template documentation is a liability for their care.  The assumption that templates are “bad” for medical documentation deserves further comment.

Many assume that physicians use this format to only improve efficiency. As far as I am concerned, nothing is farther from the truth.  Physicians have an obligation to be thorough and accurate.  Templates allow physicians to easily provide the norms of a procedure and in turn focus on the irregularities that differentiate patients and the care we then provide.

All of us are actually creatures of habit, we do most tasks in a predictable manner.  For example, if you review someone’s dictation you will find that even unique situations are identical in common procedures.  The basics about any encounter are perfect for template format.  In fact, imbedding protective language about your standard practice is an excellent way to establish that your techniques are vetted by prior practice. As an expert witness in many malpractice trials, I can say that more words are not same as more protection. Notes on previous patients cannot be used to establish a “pattern” in a trial setting. Every medical encounter should clearly capture the nuances of the procedure, findings and possible complications; templated language of the procedure allows me to focus my energy to these elements.   Additionally, description about other specific features about the patient should be captured, especially co-morbidities attached to each diagnosis that the patient carries.

Being able to personalize an electronically generated note is an important way to defuse objections about pre-formatted notes that are the basis for most electronic medical records. Ultimately, using electronic solutions should make care safer for patients by providing a framework on which to add each condition that deserves consideration while patient care plans are being shaped.

ICD-10 is here!!!  Literally.

Beginning January 1, 2011 the ability to file claims with a new form created to handle ICD-10 data went live.  All HIPAA covered entities must convert to the 5010 for electronic data interchange by January 1, 2012.  Work on the ICD-10 code set began in 1983 and was completed in 1992–18 YEARS AGO.  There are code sets for diagnoses that require much more specificity for correct usage and procedural ICD-10 codes to be used primarily by inpatient facilities.  Physicians will continue to use the CPT system for now.  Complete transition into “10″ is scheduled for October 2013 at which time “9″ will no longer be accepted.  The utilization of ICD-10 will expand the code set from approximately 16 k to 160 k options.  Practitioners who don’t take advantage of electronic options to help with patient care documentation will be losers in the war for “perceived quality care.”

We all know that the documentation has little to do with the actual care delivered but everything to do with the post care analysis of quality and appropriateness.  All physicians would be advised to prepare for the adoption of a process that can radically affect their practice of medicine.

One of the problems that proceduralists face on a daily basis is how to efficiently capture what they did in an immediate post-procedural note.

Many forces impact this process. We are busy and occasionally are distracted by other events surrounding the procedure. The dictation equipment is not always readily available or functional. Background noise can be a distraction. Discussing the procedure with family is often pressing and important. Very few of us actually realize what elements are required to bill for a certain CPT code. Using templated notes that are populated with your common procedural elements can be an efficient way to speed the process and to provide details we take for granted. We should personalize notes where needed to make them specific to each procedure realizing that we do common things commonly. Having computer access is important to be able to take advantage of the rich options this provides. So many practitioners become inundated with old medical record requirements that new ways can quickly and positively impact.

Don’t fall victim to being stuck with the habits learned over many years practice when cutting-edge technology can improve your efficiency, your patient care and your bottom line.