Standardizing Electronic Medical Record Documentation By Curtis M. Rimmerman, MD, MBA, CPE, and Arnette Colbert, MA

Transcription

1 Electronic Medical Records Standardizing Electronic Medical Record Documentation By Curtis M. Rimmerman, MD, MBA, CPE, and Arnette Colbert, MA In this article Cleveland Clinic takes on a 10-step project to improve its electronic medical record s ability to coordinate cardiovascular care. For more than 10 years, Cleveland Clinic providers have used a shared electronic medical record (EMR) for all outpatient visits spanning our hospital-based practice facilities, suburban Ohio outpatient locations, and our integrated hospital and outpatient facility in Florida. This implementation has worked exceedingly well with the advantages of an integrated EMR incrementally realized with each new EMR iteration, including the ability to communicate with patients and share testing results in a secure and expedient electronic manner. With this success, challenges have emerged, including heterogeneous electronic note structure, content and detail creating a gap between the EMR s potential and realized value. To further address EMR implementation and use within the Cleveland Clinic Heart and Vascular Institute, an outpatient directors committee was formed at the request of cardiovascular medicine departmental physician leadership. This committee was purposefully comprised of a broad range of backgrounds and expertise, including physicians from each cardiovascular medicine subdiscipline, key nonphysician administrators, a nurse leader, a business office manager and a clinical operations analyst. Shortly after forming more than one year ago, this committee set its agenda for the subsequent year and agreed to establish as a cornerstone project the development and implementation of a shared outpatient note template for the Department of Cardiovascular Medicine. The ambitious intent of this note template project was to span the five major departmental cardiovascular medicine subdisciplines and greater than 100 physicians. It also included mid-level providers and physician trainees in clinical cardiology, cardiac imaging, invasive/interventional cardiology, cardiac electrophysiology and pacing, congestive heart failure and cardiac transplantation and regional cardiovascular medicine. The opportunity Before embarking on this initiative, we realized developing and implementing a uniform EMR outpatient template note offered several advantages including: 1. Uniform note structure Note specifics documented in a similar order with greater predictability of data element content and location for internal and external constituent review. 2. Uniform branding Creation of a departmental and section-specific note template header to enable ready recognition of the note originating from the Cleveland Clinic Heart and Vascular Institute Department of Cardiovascular Medicine. 3. Enhanced content Agreed-upon review of systems and physical examination components spanning each section, furthering our goal of a comprehensive EMR outpatient encounter documentation. 4. Documentation of risk-based decision-making Emphasizing to the provider rendering the service through a feedback and educational process that the impression and plan note section is of vital importance to convey the patient assessment and management plan. 5. Documentation of patient complexity and acuity Since Cleveland Clinic is a large referral center, many of our patients are outside referrals with multiple and complex comorbidities, many of which are longstanding. Documenting the complexity of these comorbidities and, therefore, the extent of risk-based decision-making was viewed as important to support the evaluation and management (E&M) level of coding. 44 PEJ JULY AUGUST/2014

2 6. Documentation of study review Many of our patients bring with them outside paper medical records and testing images on CD-ROM on the day of their appointment or have testing performed at Cleveland Clinic after their arrival. We purposely tried to include a dedicated note template section to delineate our review of the outside paper medical records plus a separate area to delineate the external and internal testing results, documenting which tests were personally reviewed by the evaluating provider. For the rollout of the note template to be successful, we met and shared our project with high-performing EMR users whom we viewed as facile and enthusiastic adopters and successful spokespeople for our project within their individual cardiovascular medicine sections. 7. E&M coding opportunity Annually, each provider s outpatient patient encounter documentation is audited by a qualified reviewer, in our case, by the manager of billing and coding. Based on feedback from this individual, we realized E&M coding opportunities existed to better align provider documentation with the E&M coding level and believed this note template project would allow us to achieve that important departmental goal. 8. Enhanced revenue capture While this project attribute was less certain at the outset of this initiative, improved documentation including data review and capture reflecting the complexity of decision-making in the context of multiple patient comorbidities represented an opportunity to more accurately and comprehensively document our work, commensurate with E&M coding and captured revenue. ACPE.ORG 45

3 9. Create a neutral impact on provider time spent documenting in the EMR We realized as a multidisciplinary committee at project outset that for this initiative to be accepted by the entire cardiovascular medicine department physician and mid-level provider staff, it would need to be designed with time-efficient use in mind. For example, where appropriate, leveraging EHR functionality by populating the new note template using smart phrases and dropdown boxes. Additionally, for those providers using voice recognition technology, the note template would need to be compatible with present workflow and devoid of added complexity. 10. Reduced transcription Our team believed that enhancing the EMR documentation process through upfront education of the providers coupled with enhanced efficiencies of the new note template would reduce transcription time and associated costs. The process Once we outlined the opportunity, a small subset of our committee designed the new note template content with our clinical operations analyst (COA) serving as an integral liaison with information technology, transforming it into an electronic reality. We next developed the note content divided into the following sections with section-specific functionality: 1. Institute, department and sectionspecific header with an embedded Cleveland Clinic logo encounter date and encounter type clearly delineated. 2. Chief complaint Free text or voice recognition. 3. History of present illness Free text or voice recognition. 4. Cardiovascular medicine review of systems Chosen using a dropdown box. 5. Past medical, surgical, family and social history Entered and directly imported into the present and future encounter notes. 6. Allergies Entered and directly imported into the present and future encounter notes. 7. Medications Entered and directly imported into the present encounter notes. 8. Review of systems Comprehensive including at least 10 separate systems, using either a drop-down box or baseline normal review of systems, permitting editing where positive. 9. Physical examination Comprehensive with the necessary data elements using either a dropdown box or a baseline normal exam, selectively editable when abnormal. 10. Data section a) Testing results at present, manually entered or cut and pasted from the EMR; b) delineation of what tests were personally reviewed are chosen using a drop-down box. 11. Impression Entered as free text. 12. Plan Entered as free text. 13. Signature and Contact Information Smart phrase, specific for each provider. Once our note template was in a shareable format, we introduced it to the outpatient directors committee and received feedback. Their feedback was incorporated into the final note template before actual patient testing. It was soon clear, based on our auditing of documentation, that if we could achieve widespread provider departmental acceptance and use of the new note template, significantly improved documentation would be achieved. This strategy would further our mission of advancing patient care, incorporating risk-based billing and the unanticipated benefit of enhanced revenue. Discussing this project with individual physicians, one consistent misconception we encountered was that a long and detailed note was considered to equate with a higher level of E&M coding. Instead, we found this to be an educational opportunity and emphasized the importance of complexity of decision-making with the chosen level of coding aligning with the completeness of documentation and complexity of decision-making. Additionally, we were able to quickly spot EMR high performers. We learned from these providers and incorporated many of their suggestions into the final note template. The rollout For the rollout of the note template to be successful, we met and shared our project with high-performing EMR users whom we viewed as facile and enthusiastic adopters and successful spokespeople for our project within their individual cardiovascular medicine sections. This proved to be a critical decision, as we were able to gain a quick and positive foothold in each section. To our surprise, word disseminated fast as we also had physicians approach our group outside of our scheduled meetings demonstrating an interest in being an early adopter. Before rolling out the note template, we met with each provider to review our project objectives, the note structure and mechanisms. Questions were answered, and little pushback was encountered. Similar individual meetings were held with each secretary assigned to the provider to help pre-empt future questions and also to best assist with the new note template introduction. 46 PEJ JULY AUGUST/2014

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5 Finally, once this note was rolled out to the provider, a focused audit of note documentation and E&M coding began with follow-up provider meetings that included our departmental business manager. We next decided to take a section-by-section approach for our roll out and this has been an ongoing process over the past 12 months. We have been purposely deliberate with our rollout as we are striving to ensure proper and full provider use of the note template with auditing completed before moving on to the next section. Current status More than 75 percent of our physicians have been trained and are using the new note template. Although the education process with each provider takes about 30 minutes, the follow-up auditing and meetings, when needed, have extended our projected timeline as it pertains to our entire department. Likewise, our multiple geographic locations and regional physician expansion have introduced a rollout delay given the extra associated travel time. Despite our longer-thanexpected introductory phase, our new note template has demonstrated staying power. We have not witnessed any provider who has reverted to their prior documentation routine, and the feedback we have received has been either positive or surprisingly quiet. We have continued to monitor and audit the new note template usage, and our initial impressions of increased documentation, risk-based billing and accuracy of billing to the selected E&M level appear to be taking hold. We fully anticipate that the remainder of the department s providers will adopt our new note template and in the not-too-distant future, we will be able to proclaim project success on a departmental scale. Lessons learned Instituting widespread change and sustained adoption of a new means to electronically document patient care among a large group of diverse, highly independent and ambitious professionals is not an easy task. Essential to our success has been the support and encouragement of departmental leadership, a calculated approach considering and incorporating a representative number of provider opinions and a judicious roll-out plan initially working with high-performing EMR providers who we believed would readily adapt to a change in workflow. This project also brought a diverse working group together who were able to collectively agree on a singular end goal. A separate and related committee is now focusing on our hospitalized patient care documentation and how we can merge our two projects, fully leveraging the advantages of the EMR. Curtis M. Rimmerman, MD, MBA, CPE, is the Gus P. Karos chair of clinical cardiovascular medicine, director of cardiovascular medicine affiliate programs in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at the Heart and Vascular Institute of Cleveland Clinic, Cleveland, OH. [email protected] Arnette Colbert, MA, is a clinical operation analyst at Cleveland Clinic Heart and vascular Institute in Cleveland, OH. 48 PEJ JULY AUGUST/2014