Revenue Cycle Management, Medical Documentation Intersect

Featured article in ExecutiveInsight, published by Advance Healthcare Network – Feburary 16, 2015

Solutions to manage the complexities of acute care and large medical practices.

New regulations continue to drive the evolution of healthcare technology, and medical documentation is no exception. CIOs and other healthcare executives face the challenge to find solutions to efficiently manage the complexities of acute care and large medical practices while maximizing revenue cycle management in anticipation of 30 million new healthcare consumers following the implementation of the ACA and other regulations. For example, in a survey conducted by executive search firm SSI-SEARCH, a majority of CIOs reported that demands on their performance increased 25 – 50 percent in the five years since the HITECH Act passed.

At the same time, medical data continues to grow at a rapid pace. A recent report from EMC and the research firm IDC estimates that health data will increase by 48 percent annually. One of the main feeders into health care data is the electronic patient record. Hospitals are rapidly adopting EHR systems, and IDC estimates 80 percent of hospitals currently use EHRs while 95 percent will implement them by 2020.

Though the new regulations may seem daunting, healthcare providers can leverage technology and best practices to achieve high quality medical documentation in order to ensure maximum revenue reimbursement and work efficiencies.

The Evolution of Transcription and the Patient Record

Today’s CIOs and healthcare executives look to adjust to the changes in regulation and technology of medical documentation. They need to create new efficiencies while increasing the accuracy of medical documentation in order to ensure revenue reimbursement.

Capturing the patient record remains one of today’s most challenging events in medicine. It is the foundation for patient care with impact far beyond. If the information isn’t correct in the patient record and EHR, it could have negative effects on patient care as well as on insurance reimbursement and profitability of the facility.

While today’s transcription relies heavily on technology like digital dictation, smart phone apps, and cloud-based platforms, technology makes up only part of the solution. At first glance, efficiencies brought by consumerization of medical technology such as access to tablets and smart phones promise streamlined documentation capture. However, many of these methods require already over-extended physicians to edit on the front end which takes valuable time away from patient care and leaves opportunities for error in a technology only environment.

Many of these systems may rely on technology with only a few points to check for errors. Errors in medical documentation can severely impact a hospital or medical practice leading to delayed diagnoses, misdiagnoses, medication errors, or even death as well as financial consequences such as delayed or lower reimbursement and even litigation. As CIOs in healthcare manage more technology – both software and hardware – with more constituencies including physicians, nurses, lab personnel, administration, insurers, and patients, they need to ensure their systems create the highest quality patient record. In fact, their profitability depends on it.

Proceed with a Humanology Approach

Let’s look at how technology can represent a source of errors in the patient record. For example, blanks and incorrectly or unrecognized speech involving missing, improper, or questionable information in medical transcription demonstrates one of the most frequent quality issues. There may be points – blanks – where someone needs to verify terminology and fill in incomplete, absent physician thoughts along with discrepancies in information. Further, audio file distortion such as clipped, cut off, incomplete, or missing dictation as well as unknown persons or places and copied forward text can lead to blanks.

These examples of blanks illustrate how the “humanology” approach can resolve an issue. Best practices in “humanology” dictate that people or auditors review for blanks on the back end of transcription. The simple insertion of a review cycle with a human auditor can lead to higher quality transcription and a higher quality patient record. For specialty practices or specialties inside hospitals, the auditor should be an expert transcriptionist familiar with the specialty to enhance the quality assurance cycle.

Taking the Next Steps to Best Practices

While technology promises streamlined processes and efficiencies to healthcare, we must understand that only people can recognize some errors. A holistic approach to quality medical documentation wins out when we consider its strength in a healthcare setting, but also in ensuring best practices for revenue reimbursement.

Enhance the clinician environment. Determine what your clinicians prefer in terms of tools to perform documentation capture. Some may appreciate familiar equipment while others may prefer cutting-edge technology, so provide a range of options for your physicians to ensure their quality and ease of use. This also includes maintaining equipment, ensuring that security is updated, and maintaining a HIPAA-compliant environment.

Outline policies and procedures. Provide your clinicians with guidelines to help them achieve the highest standard every time. Infuse your personal approach in your place of work and remember that each practice specialty and facility is different, so your processes may vary. This remains particularly important for institutions practicing specialized medicine.

Consider your transcription team. Ensure that your team consists of experienced and dedicated medical documentation professionals. A focus on best practices to consistently deliver the highest quality in all aspects of medical practice ensures the best outcome.

Define your specialty or focus. Match your transcription provider to your facility or practice expertise and work culture. Look for vendors who understand and use specialty terminology that only training and experience can recognize. Certifications and continuous training play a part in helping your provider’s team learn more about and understand your specialty which leads to quality documentation.

Conduct quality assurance. Implementing the above steps certainly increases the chances of quality medical documentation, but the “set it and let it” mentality may decrease quality and impact revenue cycle management. Build in steps for quality assurance. Seek opportunities for continuous improvement such as regular feedback, interaction with staff, auditing, and testing to ensure high quality output.

Optimistic Outcomes

As executives in the healthcare industry come face-to-face with the rising costs in the field, high quality medical documentation is a must for increasing reimbursement and quality of care. The highest quality medical documentation not only helps patients but also contributes positively to a facility’s efficiency and bottom line in revenue cycle management.

Christopher Foley is the CEO of iMedX