Quality Assurance (QA) for Clinician-Created Documentation

The Need for Quality Assurance Patient safety can be compromised Incomplete or inaccurate documentation Lost revenue * In considering these potential negative consequences, the upfront expense of a QA program outweighs the far-reaching and long-term impacts of forgoing a QA Program. Patient safety can be compromised by incomplete or inaccurate documentation. Incomplete or inaccurate documentation will have a negative impact on coding and billing functions. Lost revenue to the facility or overpayments impact the facility’s bottom line. Damaged reputations (physician, facility, patient, etc.), accusations of malpractice, subsequent costly litigation, and even criminal penalties if billings are found consistently erroneous that they are considered fraudulent.

The Need for Quality Assurance A Quality Assurance (QA) program is not A Clinical Documentation Improvement (CDI) program QA CDI A quality assurance review ensures quality and documentation integrity. CDI professionals review documentation for “any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care,” according to AHIMA.

The Need for Quality Assurance A CDI program facilitates the accurate representation of a patient’s clinical status that translates into coded data.1 A QA program is the COMPLETE REVIEW of the narrative and demographic data to protect the patient, caregiver(s), and the organization’s documentation integrity. CDI Program: Appropriate severity of illness Expected risk of mortality Expected complexity of care QA Program: Protect patients Protect caregiver(s) Protect organizational integrity 1http://www.ahima.org/topics/cdi

The Need for Quality Assurance Organizations should incorporate BOTH programs to ensure documentation integrity and regulatory compliance throughout the healthcare continuum. QA CDI

The Need for Quality Assurance Risks of Unmonitored EHR Documentation Practices Patient Safety Financial Impact Compliance Issues Legal Consequences Patient Safety: Compromised patient safety Patient dissatisfaction/lack of trust Duplication of effort and expense Financial Impact: Delays in revenue cycle Inadequate reimbursement Increased cost of error resolution across information systems Compliance Issues: http://www.jointcommission.org/assets/1/6/2013_most_challenging_Mar_26.pdf The Joint Commission reports that 52% of their accredited organization and certified programs were not compliant with standard RC.01.01.01, which is “The hospital maintains complete and accurate medical records for each individual patient.” Legal consequences: Fraud citations Compromised organizational reputation Unreliable/invalid reporting and analytics

The Need for Quality Assurance Common EHR Practices that Create Vulnerabilities Copy and paste or “note bloat” Lack of review, correction, and feedback 3. Unmanaged/inconsistent template creation and modification leading to automation errors 4. System(s) designed and built with limited healthcare documentation expertise #3 can also include the use of macros, expanders, or different automation techniques. A QA program can effectively address each of these issues to ensure quality of care and continuity of care, and to decrease physician and clinician frustration while streamlining and supporting the documentation process. Reference “AHIMA Copy and Paste Position Statement” link in Resources slide at the end of the presentation

The Need for Quality Assurance Additional vulnerabilities: Inappropriate abbreviations Inappropriate templates Wrong patient/wrong visit Selecting incorrect check boxes Speech “wrecks” Don’ts Not using standard abbreviations Use of the wrong visit type, or wrong dropdown in the EHR forms Cut and Paste as a shortcut, leading to mistakes and misinformation Speech “Wrecks”: systems that misinterpret what the originator is saying or overlooked front-end speech recognition misrecognitions Insertion of inconsistent or lengthy progress notes or pre-completed notes Dos Support the standard of care Avoid inaccurate, outdated, or redundant information Avoid propagation of false information or typos Verify patient demographics information, medications, dosages, etc.

The Need for Quality Assurance Best practices should be used to protect the integrity of the patient’s health information. The HEART of the matter = PATIENT SAFETY Fraud is not the only concern.

CLINICAL DOCUMENTATION Complete and accurate documentation reduces errors, improves management, and ensures appropriate funding. ACCURATE CLINICAL DOCUMENTATION Fewer Medication Errors Appropriate medical care Continuity of care Improved Management System errors detected Accurate data abstracted and submitted Appropriate funding Equitable resource allocation Improved regional planning

Workforce and Skill sets The healthcare professionals behind quality assurance programs Workforce and Skill sets To Presenter: The following slides can be used if applicable to the situation. They can help explain who is behind the QA process and the importance of their skill sets.

The Role of the Healthcare Documentation Specialist (HDS) Produces documentation that reflects the patient’s story in a correct, complete, and consistent manner Ensures accurate documentation Creates a business record that can be trusted and referenced Correct, complete, and consistent. Represents the decision-making process, intentions and actions of the caregiver, as well as the course of treatment, choices, and outcomes of the patient. 3. For future research, decision making, and legal/compliance justification.

The Role of the Healthcare Documentation Specialist (HDS) Reviews healthcare documentation content and provides feedback to clinician Develops and maintains template design program Trains clinicians on template usage Collaborates with key stakeholders Includes the patient in documentation process whenever deemed possible Strives for continuous quality improvement Reviews content generated by speech recognition to QA Develops and maintains a template design program Trains clinicians on proper template use Collaborates with HIM, HIT, HDSs, and other key stakeholders Includes the patient in the documentation process whenever deemed possible Strives for continuous quality improvement, establishes and implements the feedback process

The Role of the Healthcare Documentation Specialist (HDS) Reviews and flags documentation Validates patient and visit demographics Flags critical errors for correction Identifies minor errors Provides feedback to the originating clinician Content review assists with coding and reimbursement and template creation Review, flag, and/or correct documentation Validate patient and visit demographics Review for and flagging critical errors Identify and correct minor errors Provide and request feedback from the originating physician/clinician A. Safety net (“second set of eyes”) for the clinician and the patient B. Educational opportunity for the reviewer 3. Content review assists with coding and reimbursement and template creation

AHDI-AHIMA Clinician-Created Documentation Resource Kit Error Categories Dashboards and Trending/Tracking Spreadsheets Best practices, Examples, and Templates QA Review Form Template and Sample QA Program Checklist QA Program Sample Policies/Procedures Model Job Descriptions Documentation Review Forms and Samples Video Tutorial

Resources AHDI-AHIMA Clinician-Created Documentation Resource Kit A Guide to Better Physician Documentation AHDI/MTIA/AHIMA Healthcare Documentation Quality Assessment and Management Best Practices AHIMA Copy and Paste Position Statement Dimick, Chris. "Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk." Journal of AHIMA 79, no.6 (June 2008): 40-43. The Joint Commission - Most Challenging Requirements in 2013