Health Results Team for Information Management

1
Ministry of Health and Long-Term CareHealth
Results Team for Information ManagementPhysician
Documentation Expert Panel
OHIMA Spring Conference, May 5 2006
2
Premise 1 Better health information is needed
If you can keep your head when all about you are
losing theirs, it's just possible you haven't
grasped the situation. Jean Kerr
3
Premise 2 Physician documentation needs
improvement
4
For every complicated question, there is a simple
answer and it is wrong. H.L. Mencken
What is the it that needs improvement?
5
Data quality can be improved
6
What is data quality?

• Accuracy
• Completeness
• Consistency
• Timeliness

Data Quality can best be defined as fitness for
use. Tayi and Ballou
7
Quality of care includes data quality

• 20th Century
• 1926- Francis Peabody
• The secret of the care of the patient is caring
  for the patient
• 21st Century
• W. Edwards Deming
• All quality begins with data
• J. Fitz-Enz
• Measurement of any work process or practice is
  imperative. It applies to both routinized
  process work and individual professional
  practices. Whether we are talking about a
  benchmarking project or just tending to
  day-to-day management, without number we really
  dont know what we are doing. If managers do not
  know measurements, I have only one question
  What do you think they are measuring? Without
  metrics managers are only caretakers.

8
Data quality reduces healthcare variation
A person with one watch always knows what time it
is a person with two watches is never sure.
Mark Twain
9
Why are we trying to improve clinical
documentation?

• Quality of documentation linked to quality of
  care and health care costs
• Possible outcomes of complete and accurate
  documentation

10
Poor data quality Why?
Source CIHI, 2005
11
Physician Education

• 2005 Survey of Health Records Departments
• Few hospitals have developed education packages
  on importance and use of coding and how it
  impacts weights and funding
• UHN employed CHIMA to develop disease-specific
  education packages for their physicians which
  included details on ICD-10-CA and CCI
• Quinte and St. Josephs, Hamilton highlight
  importance of coding
• 78 of respondents have educated physicians about
  submission timeframes most hospitals used memos
• CIHIs Physician Education Package focuses on
  ICD-10-CA and CCI documentation requirements, not
  on importance or use of coding

12
Lessons learned in other jurisdictions

• Physician education in other provinces is
  developed regionally
• Winnipeg Regional Health Authority developed
  package for Nursing Leadership Council that
  greatly improved documentation content included
  importance and use of coding and what information
  is required from clinicians
• St. Johns Healthcare Corporation, Newfoundland
  developed package for physicians on basic
  concepts and importance of documentation
• AHIMA has presentations and seminars that are
  targeted to HIM professionals, not physicians
  (e.g. Effective Documentation for the EHR, May
  24, 2005 Dealing with Physician Chart Completion
  Issues, May 3, 2005)
• Australia published the Good Clinical
  Documentation Guide which discusses requirements
  for good documentation, relationship between
  documentation and coding, and documentation
  pointers for 22 specialties
• Some vendors such as 3M provide physician
  training sessions to improve documentation

13
Medical School Curricula
14
Legislation and CPSO Guidelines are Broad
15
Hospital Chart Completion Policies

• CIHI, 2000 report Improving Timeliness of DAD
  Data indicated that gt90 of hospitals have chart
  completion policies fewer than 50 enforce
  privilege suspension
• Results from 2005 Survey of Current Practices in
  Ontario Hospital Health Records Departments
  indicated that
• 90 of hospitals have a chart completion process
  or policy, but only 60 believe that it is
  effective
• 89 of hospitals have policies to take remedial
  action for physicians with incomplete charts, but
  fewer than 25 them enforce it all the time
• Fewer than 10 of hospitals have extensive
  policies with well-defined definitions of
  complete charts, explicit timelines and resulting
  penalties for non-compliance

16
Current tools available for physicians

• Study in 2005 found only 58 of Ontario hospitals
  find their chart completion policy to be
  effective template for chart completion policy
  template has been developed
• Standardized inpatient discharge form developed
  by the OMA to establish minimum standard amount
  of information to be included in discharge
  document for patients leaving hospital
• CIHI has developed An Introduction to ICD-10-CA
  and CCI for Physicians to provide broad overview
  of the classification system.

17
Physician data quality strategy?

• People are much more likely to act their way
  into a new way of thinking than think their way
  into a new way of acting

Pasquale RT and Sternin J. Harvard Business
Review May 2005
18
Lao-Tzu
Change must occur from the ground up

• Learn from the people
• Plan with the people
• When the task is accomplished
• The people all remark
• We have done it ourselves

19
Practical measures are needed
In theory, there is no difference between theory
and practice. But in practice, there is.
Jan L.A. van de Snepschut
20
New initiatives must leverage information
technology
Do not be too timid and squeamish about your
actions. All life is an experiment. The more
experiments you make the better.
-Ralph Waldo Emerson
21
Physician Documentation Expert Panel - Membership

• Physician representatives from all 14 LHINs
• HRT- Information Management
• CHIMA
• OHIMA
• OMA
• CPSO
• CIHI

22
Physician Participants
Hospital Position
Hospital Type
23
Expert Panel Objectives 6 month mandate

• Approve a provincial physician education package
  for hospital-based clinicians and suggest
  appropriate mechanisms for its dissemination.
• Make recommendations to Ontario medical schools
  on enhancing their clinical documentation
  curriculum.
• Approve a provincial chart completion policy
  template, with recommendations on minimum chart
  completion requirements and time limits.
• Providing support and recommendations to the
  College of Physicians and Surgeons of Ontario to
  enhance existing documentation guidelines
• Make recommendations for future directions and
  initiatives to improve physician documentation.

24
Provincial Physician Documentation Education
Package

• Detailed background document including
• Purpose of health record
• Current state of documentation
• Impact of physician documentation
• How improving documentation improves patient care
• Appendices on key terminology, regulations,
  diagnosis typing standards and chart completion
  policy template
• One-page executive summary with key points from
  background document
• Powerpoint slide presentation to accompany
  background document

25
Purpose of Education Package

• To assist and educate physicians in
  understanding some of the key areas of health
  record documentation that can facilitate
  information exchange with other physicians,
  simplify hospital chart completion, and also
  thereby improve data extraction by health record
  coders
• To be shared with Council of Ontario
  Faculties of Medicine as a guideline for
  curriculum development for medical schools

26
Chart Completion Policy Template

• Completion of a health record after discharge is
  a component of continuity of patient care
• The purpose of the chart completion policy is to
  define a timely and consistent approach for the
  completion of health records and the application
  of consequences when health records are not
  completed
• Policy outlines hospital and physician
  responsibilities and requirements
• Policy also provides details on the minimum
  standard for a completed inpatient health record
  including
• History and Physical
• Operative Report
• Discharge Summary

27
Dissemination Strategy

• Acquire endorsement of material from partner
  organizations (e.g., OHA, CPSO, OMA, Primary
  Care)
• Package to include formal letter from expert
  panel members and testimonials from key physician
  champions
• Disseminate package to LHINs and hospitals
• Disseminate one-page executive summary to partner
  organizations for publication in their respective
  newsletters/websites
• Disseminate package to family physicians through
  Primary Care Team

28
Next Steps leveraging information technology

• Integrate clinical documentation, EMR, CPOE and
  discharge summaries
• IT support to improve clinical documentation
• Everyone should understand and use the same
  language

29
Concluding Remarks
Complete and accurate clinical documentation
enables accurate code assignment, which leads to
accurate representation of patient severity of
illness and accurate reflection of rates of
mortality and complication data. Since this
data is used for making important decisions that
impact the delivery of health care in Ontario,
accurate data facilitates equitable distribution
of resources for health care.
30
Comments and Questions

• Ralph Z. Kern MD MHSc FRCPC
• Mount Sinai Hospital and the University Health
  Network
• Neurology Program Director
• University of Toronto