Vol. 12 •Issue 3 • Page 23
What Can HIM Professionals Do About Record Completion Problems?
By Linda Gross
There are some situations that seem inherently problematic. In family life, it’s that unannounced visit from the in-laws. In personal finance, it’s the notice from the IRS that follows the refund check. And in the health information management (HIM) department, it’s that age-old problem of incomplete and delinquent records. But are there fresh ideas to the never-ending routine of hunting down doctors to complete their documentation, or are the old dogs laughing at the new tricks before they’re even out of the bag?
An Age-Old Problem, but Why?
“I think every hospital has a documentation challenge,” reflected Paula Page, RHIA, HIM director and Health Insurance Portability and Accountability Act (HIPAA) coordinator at St. Mary’s Hospital, a Tenet Health System facility in Russelville, AR. “Some hospitals are probably better off than others, but it’s still a widespread problem.” Page calls it “the 80/20 thing,” suggesting that the majority of physicians–at least in her facility–complete their documentation.
“Eighty percent of your physicians are going to do what they’re supposed to do, and then you’ve got this handful that you’ve got to coddle, beg, plead with and cajole to try to get them to complete their records.” Which still begs the question: why?
“I think there’s a couple of reasons,” offered Cynthia Doyon, RHIA, product manager, data management solutions for QuadraMed in Covina, CA. “First of all, it’s not the physicians’ priority. It’s the hospital’s need to have it done,” she said. “It doesn’t benefit the physician directly.”
“The other issue is the HIM department’s performance, and its ability to provide records in a timely and complete manner that makes it easy for a physician to complete his records,” she said. “If the HIM department is not functioning at a successful level, it becomes even harder to motivate the physicians.”
Stressing the Priority
Although it may not be an apparent priority for physicians, it’s important to the hospital that wishes to maintain its accreditation with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). According to Doyon, as part of the records review portion of a Joint Commission survey, records are deemed delinquent after 30 days, if incomplete. But the Joint Commission isn’t the only organization looking at records completion.
“The different departments of health will look at records completion if they do individual surveying of facilities, and the Medicare conditions of participation also require that you complete records in a timely manner,” said Doyon.
Of course, the key to this issue is finding ways to motivate the physicians because, as Doyon pointed out, while “legally they appreciate that records need to be signed, personally, they see the problems after the fact, and it still isn’t an incentive for them.”
Honey vs. Vinegar
Many doctors will proclaim that paperwork is tedious and it’s not the reason they went into medicine. And even if they do understand the importance of documentation, many are lost in the confusion of forms and complex processes associated with medical record keeping. This is why the Medical College of Georgia Hospitals and Clinics’ Web site features the Doctors’ Workroom, a complete page of documentation “FAQs” for physicians.
Located at www.mcghealthcare.org/hims/Phy_Wkrm_FAQs.htm, the page addresses questions such as: “When may verbal orders be given and how do I know that I need to sign a verbal order?” or, “When is a discharge order form necessary?” But the question that gets the most attention from physicians at the health care facility is “Can my paycheck be held because I do not complete medical records?”
As Melissa H. Jarriel, RHIA, CTR, director of HIM services at Medical College of Georgia Hospitals and Clinics, explained, “Resident physicians are paid by the facility, and per their contract, we can withhold paychecks for incomplete records.” Ignorance is no excuse, and the FAQ site carefully details what a complete record contains: A history and physical exam signed by the examiner, a discharge summary (if applicable) signed by the attending physician and filed in the record, all dictated operative reports signed by the attending surgeon(s) and filed in the record, and consultation requests/replies signed by the requestor and consultant. And yet, there are still offenders. “We have held a number of checks since this began in 1994,” said Jarriel.
Jarriel’s facility isn’t the only one to take corrective measures of a monetary nature. “We have problems like everyone else,” said Deb Baxter, RHIA, director of HIM at Cayuga Medical Center in Ithaca, NY. “One of the things we have started is a fining system, which kicks in after the physicians reach a certain number of suspensions a year.”
Page’s hospital uses a suspension program as well. “We keep them informed of the process,” she said, explaining that weekly letters are sent to every doctor telling them how many records need completion by a given date to avoid delinquency. “The letter goes out every week as a reminder,” explained Page. A week before the due date, “We send them a red letter—we print it on red paper—and when they see it they know that they better get themselves in here.”
But what about the old saying that you catch more flies with honey than with vinegar?
“I’ve heard of programs where physicians are bribed with food and lottery tickets,” said Doyon. “Unfortunately, many of the positive reinforcement programs have had little success because it’s just such an onerous task.”
Is the Electronic Signature the Answer?
Not every hospital’s HIM department has paycheck holding power over their physicians, but the future may prove brighter with the implementation of electronic signature technology. And hospitals like Cayuga Medical Center are taking a chance on this innovation as a possible solution to the documentation problem.
“We intend to use electronic signatures, and we are also looking at physician order entry in the future,” volunteered Baxter.
Contemplating the electronic “solution,” Doyon admitted, “It can take care of a portion of the problem” and can be implemented in varying degrees. “The most common use of the electronic signature would be in finding the dictated and transcribed reports, because they are already an electronic document,” she said, adding that in this case, physicians merely attach their electronic signature to the electronic report.
But before HIM directors pop the celebratory champagne cork, Doyon reminded, “Handwritten reports or notes are not electronically maintained in most facilities,” which means that unless a facility has a truly electronic medical record and the physician is making digital notations at the point of care, the handwritten notes won’t be affected.
With electronic technology on the horizon, the problem may not be eliminated, but the promise of improvement is still an inviting prospect.
Linda Gross is an assistant editor at ADVANCE.