“Deep disorder pervades medical practice. Disguised in euphemisms like “clinical judgment” and “evidence-based medicine,” disorder exists because medical practice lacks a true system of care. The missing system has two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards. Electronic information tools are now widely discussed, but the necessary standards of care are still widely ignored. Because these two elements are external to the physician’s mind, they address a root cause of disorder: dependence on the internal capacities of autonomous physicians–their personal knowledge, intellect, habits and judgment. In this dependence on the limited, idiosyncratic capacities of individuals, medical practice lags centuries behind the domains of science and commerce.”Quote from Lawrence Weed, in an interview for NIH.gov in 2009:
“It is important to understand that the discipline imposed by the POMR has not been fully embraced. Too often the POMR is sporadically employed as a convenience, not consistently enforced as a discipline. One reason is that medical education is fundamentally incompatible with the underlying philosophy of the POMR. Medical education seeks to instill medical knowledge and “clinical judgment.” In doing so, medical schools give students a misplaced faith in the completeness and accuracy of their own personal store of medical knowledge and the efficacy of their intellects. What is done to students in medical school is the antithesis of a truly scientific education.”
Is Documentation Really The Issue?
In my talks, articles, and discussion group, Finally Friday!, I have focused on changing documentation in the medical record – not simply physician documentation, but all documentation. The reason for my focus is because my 40-year career in marketing and production taught me that in ALL situations, it is possible to find a rather simple but highly effective solution to a problem by finding and focusing on the one thing that causes most if not all of the trouble in a system. I firmly believe (and can logically prove) that physician documentation is the key to reducing, and even eliminating, payor denials.
Will that fix all revenue cycle management (RCM) or revenue integrity issues? No. But it will solve a huge majority of the issues – especially if you consider the cost-benefit ratio of the money being thrown at RCM by hospitals, since the appearance of the RACs (Recovery Audit Contractors) in 2005. Even the RAC demonstration project proved this point for me, by 2008: over 48% of errors found by the RACs involved documentation, and another 35% were blamed on “incorrect coding” – which is of course based upon documentation or the lack thereof.
“Processes” Are Always Important
My own expertise is process, not medicine. Because of that, I am perhaps not emotionally “connected” to documentation in the same way that a physician may be, or may seem to be. After all, I do understand that physicians often feel like they are being “second-guessed” by auditors, who are not physicians. Nevertheless, if there is to be a solution to this mess – with over 800,000 appeals now on hold at the 3rd level of the Medicare appeals process – the core issue must be addressed — how physician documentation is written.
Auditing is not going to go away, and indeed it should not go away. But since no payor can afford to hire physicians to audit records, neither the qualifications of auditors, nor the audit methods being used by those auditors are likely to change, any time soon. If providers hope to avoid audits and reduce subsequent denials, then providers are the ones who must affect a change in the way they operate, or face growing losses, which inevitably will lead to lower quality and quantity of care in our country.
Documentation is Not a New Subject
I am not alone in wanting to change documentation, and really I’m rather a Johnny-Come-Lately. It is encouraging to me that there are people who know medicine, and the practice thereof, who want to change physician documentation, for albeit wholly different reasons. Case in point – Dr. Lawrence Weed, commonly considered to be the father of the SOAP note and the problem oriented medical record (POMR).
Dr. Weed introduced the POMR in the 1960s because he wanted to provide a more patient-centered approach to the structure of the medical record. Dr. Weed, and many others since then, have made the point that the medical record is a communication tool, and has always been used by many different parties, for differing uses.
Here is a list of the users and uses of the medical record, as listed in “The OTA’s Guide to Writing SOAP Notes“:
- Client Care Management (treatment team)
- Reimbursement (billing, reimbursement)
- Legal System (testimony)
- Quality Improvement (appropriateness, adequacy)
- Research and Evidence Based Practice (research)
- Accreditation (meet standards of care)
- Education (teaching tool)
- Public Health (vital statistics)
- Utilization Management (efficiency, effectiveness)
- Business Development (marketing, planning)
- The Patient (the one who really owns the record)
Even more importantly, however, is his point expressed in the 2009 interview quoted above, which I would paraphrase like this:
“Deep disorder pervades medical practice… disguised in euphemisms like “clinical judgment” and “evidence-based medicine,” [lacking] a true system of care, [because it is missing] two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards.”
What Should We Conclude?
I have to say that I for one am in total agreement with Dr. Weed. What we have today is a lot of fuss over Electronic Medical Records (EMR) – at this point, an attempt by the government, arguably not from the industry itself, to implement tools that are aimed at reducing costs, end of story. Of course, it is not “marketed” or presented to the public as such. But it is the politicians pushing EMRs as a way to improve care. Can you trust politicians to ever present their true agenda? Ok, maybe I’m jaded, but do you really think they don’t have hidden agendas? Gather all the conviction you may have on the subject and ask this question out loud: “REALLY???”
There is a HOPE that better care comes out of all this. But forget all the rhetoric, forget all the speeches, forget all the debate. Look at the woeful results. Oh wait. Tell me if you can actually FIND any published “results”?
I see no “results” being published, or , in my opinion, what has been measured is essentially meaningless. I’d be happy to review anything meaningful. For that matter, to be fair, I suppose I should be willing to review anything “presented” as meaningful, though I reserve the right to remain dubious.
Meanwhile, I have to agree with Dr. Weed.
Join our discussions about all this on Finally Friday!