Improved documentation: leveraging staff training, benchmarking, technology, and process change for accurate payment

Healthcare Financial Management, April, 2008

But formal departmental meetings go only so far.

"In any given hospital system, a departmental meeting will capture only about half of the physicians who need to be involved. So you can't just do that and assume everyone will know what's going on," Sentara's Swaim explains.

Sentara--like St. Vincent, Sun Health, and Humility of Mary Health System in Youngstown, Ohio--has cast a wide educational net.

Sentara's concurrent documentation program takes advantage of forums such as grand rounds and subspecialty meetings, and it targets physicians' assistants to help physicians understand why they are being asked for more information. Early on, the program named a senior medical staff leader as a co-administrative leader of the project, and it made the vice president of medical affairs the point of contact for physicians at each site. The vice president of medical affairs not only helps to introduce the concurrent documentation program to physician specialties, but also works one-on-one with physicians or specific physician groups who do not understand the benefits of the program and why they need to cooperate.

Senior physician leadership is key at the other organizations as well. St. Vincent's medical director for case management plans and coordinates training programs for the system's medical staff and writes white papers as well as articles on documentation. Sun Health has placed at each of its two hospitals a general oversight physician advisor. At Humility of Mary Health System, the chief medical officer fills in gaps in the educational process for physicians and residents in training.

Typically, a second wave of support comes from clinical documentation liaisons or specialists--the frontline staff who deal directly with physicians on a day-to-day basis to identify what's in the medical record and, more important, what's missing.

Clinical documentation specialists on patient care units can provide vital reinforcement and on-the-spot training for physicians. "Physicians can't remember everything, so these are the people who are on the floors to assist and prompt, and leave queries for physicians," explains Minick of Sun Health.

At Sentara, nine concurrent documentation specialists are either registered nurses or licensed practical nurses. The specialists work with physicians to replace implied with explicit medical detail, clarify diagnoses that are present on admission, and add descriptors that precisely define a condition or procedure.

Sun Health hired six nurses to act as documentation liaisons and conduct concurrent chart review on all 24 nursing units. The goal is to review 85 percent of all Medicare admissions every day. The documentation liaisons pull the lists of admitted patients every morning and within the first day of admission fully review the chart and start the query process with physicians. They also are the link with coders in the health information management department in a tandem approach to make the information as accurate as possible.

"They are chart auditing in real time," says Minick. "They fill out a face sheet of their interpretations of the patient's condition, primary procedures, diagnoses, present-on-admission diagnoses, etc. That face sheet then goes through a prebilling auditor in our health information management department and then to coding."