Documentation Not Administrative Burden Says OIG’s Taitsman

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Original story posted on: November 18, 2013

Listeners to RACMonitor’s “Monitor Monday” may have heard the Nov.18 edition that featured Julie Taitsman, MD, JD, chief medical officer of the Office of Inspector General, discussing the OIG’s efforts at reducing fraud.

She was discussing the importance of accurate medical records and stated that medical record documentation is not an administrative burden, as many physicians argue, but rather an essential component of good quality care and protects patients. She gave the example of a patient’s allergy being recorded improperly as an example of the potential harmful effects of poor medical records. She also stated, with one of those quotes that deserves to be placed on a plaque in the physician’s lounge at the hospital, “Bad things happen to patients if the medical records are not accurate.”

But aside from inaccuracies in recording medications and allergies, isn’t it really just an administrative burden on doctors to have to ask and record a patient’s past medical history and review of systems and actually examine their whole body and record the results? Does it really matter if there is not documentation in the hospital medical record of all conservative treatments tried prior to surgery for patients undergoing total joint replacement?

In the field of medicine, the way to answer a question is with a study. And, lucky for us, such a study was performed in 2008 by a group at the Duke Clinical Research Institute.

These researchers looked at the medical records for 607 patients admitted with non-ST elevation acute coronary syndrome at 219 hospitals. The records were scored on a 20-point scale based on the inclusion and level of detail of key elements, including the history of present illness, medical history including medications, results from physical examination of key systems, laboratory data, and medical decision-making which included the documentation of a problem list, differential diagnosis, discussion of comorbid disease (eg, diabetes and hypertension), and use of Evidence-Based Medicine (EBM)-based treatments (eg, aspirin, β-blockers, glycoprotein IIb and IIIa inhibitors, or heparin). The records were then reviewed for “quality of care” based on the proper use of EBM-based therapies and in-hospital mortality.

The results were impressive.

There was a direct correlation between the quality of the medical record and the quality of care, with hospitals with better medical records providing better EBM-based care, and an inverse correlation with mortality, with hospitals with better medical records demonstrating a 21 percent reduction in in-hospital mortality risk for every 5-point difference in medical record quality.

So what about the joint replacement? Isn’t it all about payment? While a study has not been done comparing the care of these patients as was done with acute coronary syndrome, imagine the physical therapist or physical medicine physician being asked to see a patient post-joint replacement to plan their therapy and post-discharge needs. The patient has just received a small dose of narcotics for pain and can’t quite recall if, when, or where they had physical therapy. They can’t quite remember how many stairs there are to get into their home or how well they were able to navigate those pre-surgery. They remember they took a pain medication but not the name, the dose, or why they stopped it. You could see how developing a plan of care for a patient such as this would be difficult, and a good pre-surgical note explaining these elements would enable those providers to provide better quality care.

We also live in an increasingly fragmented medical world. Patients have their primary care physician but many also see several specialists as an outpatient. When hospitalized, they are seen by an emergency department doctor, then transitioned to a hospitalist, seen by a myriad of other specialists, provided nighttime care by another set of physicians, cared for by two or three different nurses each day, evaluated by educators and therapists, followed by a case manager and possibly a social worker, and upon discharge, transitioned to another setting, perhaps a skilled nursing facility where a SNFist takes over, or to a home care agency with another set of nurses and therapists. These other caregivers depend on a complete and accurate medical record to be able to provide quality care.

In fact, CMS recognized the importance of the medical record as an essential communication tool in its reviewed interpretive guidelines on discharge planning released on May 17, 2013, stating, “The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services (including physician offices), as needed, for follow-up or ancillary care.” (Emphasis added.)

So, as Dr. Taitsman said, good medical records are clearly not an administrative burden; on the contrary, they are one of the crucial steps to providing quality care to our patients.

When physicians roll their eyes at you for suggesting such, remind them that as with the care they provide, there is data to support that high-quality medical records result in high-quality care.

About the Author

Ronald Hirsch, M.D. serves as vice president of physician advisory services (AccretivePAS®) in the Regulation and Education Group (“the REG Specialists”). Prior to his employment at Accretive Health, Dr. Hirsch, a board certified internist and HIV specialist, practiced and served as president at a multispecialty practice in Illinois, and medical director of case management at Sherman Hospital in Elgin, Ill.

Contact the Author

RHirsch@accretivehealth.com

To comment on this article please go to editor@racmonitor.com

References:

You can read the study from Duke at: http://goo.gl/6xZUtu

You can read the interpretive guidelines at: http://goo.gl/29A6S

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