QA of EHR Documentation: The Quest for Quality beyond CDI

Jill Devrick, MPA Past President, AHDI National Leadership Board

Product Manager, 3M Health Information Systems

Modes of Documentation Capture

• Handwritten notes

• Dictation and transcription – paper

• Dictation and transcription – electronic

• Speech recognition technology

• Templates in the electronic health record

• Clinician mobile devices

Why Create Documentation?

• Continuity of patient care

• Information sharing

• Legal due diligence

• Financial justification

• Research

• Clinical decision support

The Way We Were

Chart EHR/EMR

Patients Clinical Colleagues

Office Staff Insurance Companies

Legal/Compliance/Risk HIM/CDI/Coding

HIT Physician

Healthcare Documentation Specialist

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The Way We Are

Chart EHR/EMR

Patients Clinical Colleagues

Office Staff Insurance Companies

Legal/Compliance/Risk HIM/CDI/Coding

HIT Physician

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6

Risks of Unmonitored

EHR Documentation

Practices

Patient Safety

Financial Impact

Compliance Issues

Legal Consequences

7

A Quality Assurance (QA) program

is NOT a Clinical Documentation Improvement (CDI)

program.

QA CDI

• A CDI program facilitates the accurate representation of a patient’s clinical status (severity of illness, risk of mortality, complexity of care) that translates into coded data.

• 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 vs. QA

Organizations should incorporate BOTH

programs to ensure compliance throughout the healthcare continuum.

9

QA AND CDI

Common EHR Practices That Create Vulnerabilities

1. Copy and paste or “note bloat”

2. Lack of review, correction, and feedback

3. Unmanaged/inconsistent template creation and modification

4. System(s) designed and built with limited healthcare documentation expertise

Additional Vulnerabilities

1. Inappropriate abbreviations

2. Inappropriate templates

3. Wrong patient/wrong visit

4. Incorrect check box selection

5. Speech “wrecks”

QA FOR CLINICIAN-CREATED DOCUMENTATION

Would you want these errors in your medical record?

QA FOR CLINICIAN-CREATED DOCUMENTATION

Would you want these errors in your medical record?

QA FOR CLINICIAN-CREATED DOCUMENTATION

Would you want these errors in your medical record?

QA FOR CLINICIAN-CREATED DOCUMENTATION

Would you want these errors in your medical record?

QA FOR CLINICIAN-CREATED DOCUMENTATION

Would you want these errors in your medical record?

SPEECH WRECKS

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.

ACCURATE CLINICAL

DOCUMENTATION

Fewer Medication Errors

•Appropriate medical care

•Continuous care

Improved Management

•System errors detected

•Accurate data abstracted and submitted

Appropriate Funding

•Equitable resource allocation

•Improved regional planning

The Role of the Healthcare Documentation Specialist

1. Produces documentation that reflects the patient’s story in a correct, complete, and consistent manner

2. Ensures accurate documentation

3. Creates a business record that can be trusted and referenced

• Reviews content and provides feedback to clinician

• Develops and maintains template design program

• Trains clinicians on template usage

• Collaborates with key stakeholders

• Includes the patient whenever possible

• Strives for continuous quality improvement

The Role of the Healthcare Documentation Specialist

• Reviews and flags documentation Validates patient and visit demographics Flags critical errors for correction Identifies minor errors

• Provides feedback to the originating clinician Safety net (“second set of eyes”) Educational opportunity for the reviewer Pre-CDI content review to assist with coding and

reimbursement and template creation

The Role of the Healthcare Documentation Specialist

Clinician-Created Documentation Tool Kit

• “Why?” White Paper

• QA Error Categories

• PowerPoint Presentation

• QA Program Checklist

• QA Program Policy/Procedure

• Model Job Descriptions

• Trending/Tracking Spreadsheets with Examples

• Trending/Tracking Spreadsheet Template

• Clinician-Created Documentation Review Form

• Clinician-Created Documentation Review Sample with Errors

• Clinician-Created Master QA Form

• Dashboard Examples

• Dashboard Templates

• Dashboard Best Practices

• Video Tutorial for PowerPoint Presentation

Clinician-Created Documentation Tool Kit

Recommended EHR QA Best Practices

• QA all content generated by speech recognition

• Develop and maintain a template design program

• Train clinicians on template use

• Collaborate with HIM, HIT, HDS

• Include patient when possible

• Strive for continuous documentation improvement

QUESTIONS

Jill Devrick, MPA Past President, Association for Healthcare Documentation Integrity

Product Manager, 3M Health Information Systems jdevrick@mmm.com

Resources

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