In my last two “Oops Factor” posts, I discussed the necessity of addressing critical errors in healthcare documentation that could affect patient safety, as well as non-critical errors which may not harm the patient, but could impede the reader’s understanding of the content. But what about the nitpicky stuff? How far should editing go in the electronic world in which we now work?
I remember when I started consulting with hospital transcription departments almost 20 years ago that it mattered very much how the document appeared on paper and that every detail of spelling, grammar, punctuation, and other stylistic rules were maintained. Nowadays, adoption of speech recognition and direct EHR entry have fostered a new mindset of getting the documentation created as quickly as possible without worrying about minor issues. The advent of this mindset is in direct correlation to the expectation that the new technologies are efficient enough that physicians and other clinicians should create their own documentation without assistance. Continue reading
At the start of the New Year, I can’t help but reflect on how much patient care has changed in my 25+ years. Many things that were common practice back then were either not necessary or even sometimes harmful. An example would be Foley catheter placements. Foleys for “everyone” whether they needed them or not!
However, the advent of superbugs with increasing antibiotic resistance has also meant an increase in catheter-related UTIs. Organizations became focused on prevention, using different catheter materials thought to prevent colonization, and by evaluating the need for insertion and/or continued placement. It certainly didn’t hurt that catheter-associated UTIs (CAUTIs) were determined to be hospital-acquired preventable conditions that CMS would not reimburse, and were also factored into quality outcomes metrics by quality assessment programs or organizations. Continue reading
Back in September, I wrote a blog about documentation errors and listed various types of critical errors that could potentially impact patient safety, care, or treatment. Clearly, errors that can cause harm are the first and most important to detect and resolve. Some errors don’t carry such severe potential consequences, but they still impact documentation quality.
Why should we be concerned about noncritical errors if their presence does not hurt the patient? First, these errors can affect perception about the author and/or organization if they are not addressed and corrected, especially if frequent or habitual. No physician or administrator wants to be questioned in court concerning incomplete, inaccurate, or just plain sloppy documentation because it introduces doubt regarding the attention to detail and professionalism of the organization and individuals providing care to the patient. Continue reading
On September 4, 2014 CMS replaced Transmittal 534 with Transmittal 540, Change Request 8802 to “adhere to CMS Inpatient recoding policy standards, which was accomplished by removing the recoding language in section 3.2.3 in the Manual Instructions.” They went on to specify “The purpose of this CR is to allow the MACs and ZPICs the discretion to deny claims that are ‘related’ and provide approved examples of such situations.”
Effective September 8, 2014 CR 8802 allows MACs and ZPICs to deny “related” professional claims submitted before or after the facility claim being questioned. CMS determines that “documentation associated with one claim can be used to validate another claim, (then) those claims may be considered ‘related.’” Continue reading
The MU of NLP. Haven’t heard of that yet? Well, it’s a new concept and I think it’s going to become as standard and important as Meaningful Use of EHRs. As important as MU is for EHR adoption and in fully evolving healthcare from the paper era, the true revolutionary advances are going to come from making sense of all of the digital data being collected in an electronic health record.
So, what are the Stage 1 requirements for meeting Meaningful Use of Natural Language Processing? The criteria are twofold. The first part is the criteria for establishing a fully integrated NLP platform with your clinical workflows. The second part is meeting two key use cases. Continue reading
When reviewing and evaluating healthcare documentation from a quality and integrity perspective, a QA reviewer is looking to capture and address any error, regardless of source and severity. However, some errors are more critical in nature because of their potential impact upon patient safety, care, or treatment. Other errors may have an impact upon documentation quality, but their presence does not change the meaning of a document or affect patient care. In this post I would like to discuss critical errors discovered through documentation QA, but stay tuned for future posts addressing noncritical errors and educational feedback opportunities. Continue reading
Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?
Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading
The other day, I was thinking back to the year 1987: Ronald Reagan was President, the New York Giants won the Super Bowl and the Minnesota Twins won the World Series. Michael Jackson released his third album, Bad, and “Walk Like an Egyptian” by the Bangles was the number one hit on The Billboard Top 100.
1987 was also the beginning of an important initiative in healthcare and health information management. This was the year that 3M created its inpatient clinical documentation improvement (CDI) program. Continue reading
Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading
Last week I attended my first CDI Summit. As a specialist in the document creation process, I knew that I was going into the conference with a different perspective on healthcare documentation than most attendees, but I was hoping to see how the goals and processes of clinical documentation improvement (CDI) align with the goals and processes of documentation capture and quality assurance.
I was happy that all of the sessions I attended related in some way to how the documentation is being captured in health care, either through traditional dictation and transcription, speech recognition, templates, or direct data entry. On several occasions I heard the CDI mantra, “If it isn’t documented, it didn’t happen,” because the focus of CDI is on attaining accurate and timely documentation that reflects the scope of services provided to the patient. Continue reading