Documentation can be a headache for everyone, from the physicians who have to take precious time away from patients to document in the EHR to the case managers who have to track the physicians down to fill in gaps when information is missing from the medical record.
The case manager plays a crucial role in helping to make sure medical record documentation not only supports billing and coding to ensure accurate reimbursement, but also clearly communicates the patient's condition to the entire clinical team.
It needs to be complete, accurate, succinct, and effective, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at Zirmed. However, it's often anything but. Krauss says he often comes across documentation that case managers could help clarify, and he recently offered some real-life examples (with details changed to protect patient privacy) to illustrate key points.
Case managers can help resolve common problems found in patient charts, including insufficient clinical information and missing basic information.
Few in the healthcare industry would argue that the way the government currently pays for drugs is the most cost-effective, efficient, and equitable method possible.
CMS proposed an extensive five-year, two-phase plan to overhaul Part B drug payments for physicians and hospitals in March outside of the normal OPPS rulemaking cycle that could be implemented as early as this fall.
Accurate patient matching within the EMR should not be a concern limited to HIM professionals. Ensuring that medical record data is correct and complete and that duplicate records are not created is key to various healthcare initiatives, including population health management, analytics, information governance, patient-centric care, health information exchanges, and finance. It all starts with the patient's record. Reducing the number of duplicate records at a hospital and being able to effectively match records is critical to ensuring that these healthcare initiatives are successful, says Lesley Kadlec, MA, RHIA, CHDA, director of HIM practice excellence for AHIMA.
"Patient matching is really the underpinning of all the strategic initiatives that are going on in healthcare," Kadlec says. "You have to have accurate patient information to have accurate patient care. Ensuring that you have the right patient and the right information at the right time is really what drives the physicians' and clinicians' ability to actually provide that patient with care."
More than half of HIM professionals work with mitigating duplicate patient records, and of that group, 72% do so on a weekly basis, according to a recent survey of AHIMA members. Unfortunately, less than half of all respondents have quality assurance in place for their registration or post-registration processes. (A summary of the data is available in the Journal of AHIMA.)
"The challenge is having the staff to be able to dedicate to making the corrections, doing the matching, and ensuring that everything is getting put back together," Kadlec says.
Patient matching and duplicate records are a major issue right now because hospitals are using so many different systems and there is often a lack of information governance across those systems, says Megan Munns, RHIA, identity manager at Just Associates, Inc., based in Denver.
Last year, as ICD-10 implementation approached, organizations throughout the U.S. reported varying levels of comfort with regard to readiness and understanding of the impact of ICD-10 on physician workflow. For some, it was business as usual. For other physicians, ICD-10 became one more check box on the list of reasons to leave practice.
