As hospital leaders, RAC teams, HIM directors, case managers, documentation specialists and others deal with an increasingly adversarial denial industry, many often wonder “Why can’t physicians just do it correctly?”  

While many physicians can improve the quality of clinical documentation to collaboratively assist in preventing or responding to denials, let’s consider the question in the context of the transition to the electronic medical record (EMR).

Do you recall the promises, perhaps a decade ago, of the changes that would occur with the EMR?  Data would be accurately and perhaps automatically captured, physicians would have rapid access to a comprehensive medical record, recorded longitudinally over time, to allow more accurate diagnoses, improved patient safety and quality, an enhanced practice satisfaction and efficiency.  As is often the challenge with complex systems, simple solutions often lead to unanticipated consequences.

Cut and Paste Notes

As hospitals have incrementally implemented EMRs, individual caregivers are providing more and more detailed documentation.  Many providers such as dieticians, nurses, physical and occupational therapists and others now create progressively comprehensive documentation.  While conceptually improving quality, few physicians have the time (or patience) to review multiple lengthy, repetitive, and at times uninformative notes.  Physician notes themselves have expanded as physicians attempt to remain compliant with increasingly complex professional billing requirements.  Many hospitals have enabled “cut and paste” which theoretically might improve efficiency of documentation, but more frequently results in more words, but less credible information.

I was recently informed by a group of hospitalists that they spend less than 20 percent; of their time in actual patient care.  Deciphering the EMR, identifying Present on Admission conditions, reading documentation, doing their own documentation, attempting to communicate with other clinicians and other activities increasingly cut into their time, decreasing efficiency and professional satisfaction.

Team Approach

As the healthcare industry transitions fully into the electronic era and attempts to resolve many of these challenges I would also suggest that we need to consider a change in physician attitude – what we would have called in the ‘90s a “paradigm shift.”  I was trained as a surgeon; that I was the “Captain of the Ship” and was responsible for all details of care.  A much more applicable metaphor in today’s environment would be the pilot in command of a commercial aircraft.  One of the most significant interventions in the past 20 years to increase the safety of commercial aviation has been to decrease pilot workload.  Aviation had the novel idea that pilots should actually have time to think.  How do they do it?  They rely on others.  Their team includes ground crews, flight attendants, and perhaps most importantly Air Traffic Control (ATC).

From personal experience, I have found it exceedingly gratifying when ATC informs me of the location other aircraft or embedded thunderstorms when flying through clouds in instrument conditions.

What can we learn from this model?  Increasingly case managers, coders, documentation specialists, clinical integration specialists and others need to evolve the infrastructure and skills to provide “situational awareness” for the clinical treatment team.  This will involve the development of new information technology tools, enhanced team communication, as well as a change in physician attitude.  We are seeing it happening at an increasing number of hospitals.  Perhaps the best example of a team approach I have seen recently was in an ED Trauma bay where a multiple trauma victim was being intubated by the anesthesiologist, orthopedically stabilized by the ortho resident, assessed by the general surgery resident (testing the abdomen for blood), and generally prepared by the IV team, ED nursing staff and others.  Where was the trauma surgeon?  Analogous to the pilot in command, the trauma surgeon was standing in the back, arms crossed, observing the activities of all members of the team, … and … most importantly, …thinking.

All members of the clinical team; nurses, physicians, documentation specialists, dieticians, case managers, therapist, clinical integration specialists, and others need to continue to evolve their roles to enhance the team approach to attaining the most accurate documentation of clinical diagnoses and treatment of every patient to support collaborative efforts to avoid take-backs from the ever-growing denial industry.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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