February 10, 2014

Tell Me a Story

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In preparation for ICD-10, there have been innumerable articles published and presentations delivered on lack of physician engagement, how to engage physicians, clinical documentation improvement needs, lack of specificity needed for coding – the list goes on. It seems we are working so hard helping physicians prepare that we have failed to listen to them. When we really do listen to them, an “a-ha moment” suddenly occurs. Instead of focusing on all the things they need to document and all the things they are doing wrong or poorly, try focusing on the story they want to tell.

 

We recently were asked to provide assistance to a group whose management and physicians were at loggerheads. We asked their coders to select some less-than-ideally documented medical records. We then scheduled 30 minutes with each physician, at a time that was convenient for them, away from the clinical area. The first meeting was with an oncologist. Based on the medical record documentation of one case, the only thing we really knew was that the patient had metastatic cancer, with an original diagnosis made 10 years ago. Without even looking at the documentation, I asked the physician to tell me about the patient. He immediately gave the complete history and current picture, including the sites of metastasis, type of cancer, current treatment, that there was no recurrence at the original site, etc. I asked why he did not tell me those things in the record. He responded, “no one ever told me I had to or I did not get paid.” Well, shame on us! Although we likely would never accept poor work on our cars or homes, we have a history of accepting poor documentation. Why? Because we could.

That story provided the opportunity for a meaningful discussion. When the physician realized that, from the payor and/or quality care perspective, his claim would tell them that he is an oncologist treating the patient for cancer, but “I don’t know where,” he was shocked. The door was opened for a patient- and provider-centered dialogue on how to improve documentation by simply telling a story for each visit.

Arguably, the most challenging arena is diagnostic specialties. Many times I have thought that some of these exams, especially when ordered from emergency departments, are like The Mystery of Edwin Drood: an unfinished story with an unknown and only-to-be-guessed-at ending. These specialties are particularly difficult because they may have no interaction with the patient and are reliant upon the ordering physician – to a point. In spite of these challenges, telling a story also can work effectively when all involved physicians and departments work together.

We started with a CT of the head. The order stated “ankle injury,” and so did the report indications. The exam was negative. We asked the radiologist to explain why advanced imaging and exposing the patient to radiation was appropriate for the indication stated, plus what he was looking for and why. He opened an electronic file and explained that the technologist interviewed the patient, who stated that he had fallen, struck his head, and developed a headache, blurred vision, and dizziness. When asked if that was important to him, the radiologist explained exactly how important it was. When asked why he did not include it in his report, he stated that it was because it was not on the electronically entered order from the emergency department. I asked him to pretend for a moment that he was reviewing the case for payment and/or quality care and patient safety. You told me you performed an expensive exam of the head and radiated a patient for an ankle injury. Really? Of course not. So tell me the story using all available, appropriately documented information. Clearly, it then made sense.

The next steps were to have the radiologists and the ED physicians sit down and discuss the stories they needed to tell. Procedures to incorporate the complete and correct information into the orders and the radiology reports were developed.

Lastly, we tackled the issue of true stories versus fiction. The problem of false information not only brings the veracity of the entire record into question, it can jeopardize the patient and create enormous challenges tied to correcting those records. In the current environment of electronic records, it is very easy for erroneous information to populate multiple physician records. We found that the physicians we spoke with were shocked by the number of significant factual errors in their documentation that went unnoticed. Examples included medication allergy discrepancies, incorrect personal histories, injuries certain patients did not actually have, and more. Did they mean to write fiction? Of course not. Will they be more careful to write true stories in the future? We hope so.

In conclusion, we found that this approach worked better than anything else we have tried. It focuses on what physicians know best: their patients. It creates the chance to show them how to write their stories in a way that works for coding, quality, and care.

Ask your doctors to tell you a story.

Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.