Many say that medicine is both art and science. It draws on the rich traditions of ancient Egyptians, Greeks, and Romans, who recognized the value of keen observation, expert listening skills, and disciplined documentation of findings. Modern-day physicians emerge from years of medical training, residency, and fellowship programs with expertly honed observation and listening skills and a wealth of accumulated knowledge about the mysteries and marvels of the human body and the many ways its exquisite organs and systems can fail. How they convey the story of each patient encounter has a tremendous influence on treatment, and impacts the increasingly complex business relationship between providers and payers.According to a study by Kaufman Hall released this past April, in 2013 there were 98 new combinations—a 3 percent increase from the previous year and a 51 percent increase from 2010. Documentation is increasingly important to hospitals, as profit margins are squeezed and denials and audits have an often disastrous effect on cash flow.
Independent doctors have traded the freedom of autonomy for the safety of a protected work schedule, a guaranteed salary, and escape from the back-office rules and regulations that often overwhelm them. Many industry observers studying the phenomenon estimate that as few as 25 percent of physicians remain independent, and that percentage will continue to plummet as older ones leave the profession early and the newly licensed join corporate staffs. As hospitals increasingly recognize the role that documentation plays on patient outcomes and profits, it is likely they will expect more from physicians in terms of quality of documentation.
And as transparency between physicians and patients increases through physician profiling websites like Healthgrades, clinical documentation will also be more closely scrutinized.
Healthcare is also rapidly pivoting away from autonomous decision-making controlled by one physician treating a patient, toward teams of clinicians whose judgments will be influenced by what is, or isn’t, captured in the patient record. One physician’s incomplete documentation may have ripple effects on the decision-making of another physician treating the patient.
“The rapid emergence of electronic health records has many physicians drowning in a sea of data,” Einhorn contends. “They struggle to stay afloat, because while the data EHR’s capture is vital to seeing the whole picture of each individual patient, the way in which it is captured and collated makes it difficult to connect the dots. And that’s what physicians must do. They must observe, listen, and document. The story their documentation tells must convey more than just a chief compliant, recording of vitals and review of systems. It must bring to light additional factors and common comorbidities that may influence care decisions.”
Many physicians have a poor understanding of how the way in which they document influences the proper remuneration they receive for services. That’s not surprising, given the complexity of regulation and the pace of yearly modifications to each system.
Einhorn steadfastly believes that adoption of ICD-10 is good for documentation, and that many of the principles of the new code set —laterality, increased anatomical specificity, noting episode of care or trimester of pregnancy—have long been captured in patient records by physicians who are good documenters.
Many EHRs don’t have adequate ICD-10 solutions that aid superior clinical documentation. In filling this void, a new generation of Computer Assisted Clinical Documentation Improvement software is helping to focus physicians on this critical component of quality care.
“In the end,” says Einhorn, “those systems that are clinically friendly, interoperable with the EHR, and aid in facilitating the most complete documentation, because they offer guidance, will be the ones that physicians use.”
About the Author
Jackie Morey is the co-founder and chief marketing and sales officer for ICDLogic, a company that provides fast, easy and accurate clinical documentation improvement software tools for clinicians, coders, billers and administrators.
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PROGRAM NOTE:
Dr. Einhorn will be conducting a complementary webcast entitled, “The Untold Story: If it isn’t documented, it didn’t happen,” on Thursday, Oct. 2, 2014 at 1 p.m. Eastern.
