Don’t be lulled into a false sense of security; take control of your electronic medical recording.
By John Wallace, PT, MS
Healthcare information technology (HCIT) continues to reshape the outpatient physical therapist practice. Emerging reporting requirements, including functional limitation reporting (FLR), participation in the physician quality reporting system (PQRS), and tracking clinical outcomes have actively pushed practices to adopt a variety of technical solutions.
These solutions may help us achieve greater quality in our practice and patient management; however, the solutions also bring a set of subtle risks that are typically not obvious to practice owners, managers, and therapists.
Electronic medical records (EMRs) applications are perfect examples of the seductiveness of HCIT in practice. Payers, including both Centers for Medicare and Medicaid (CMS) and commercial health insurers, are reviewing more records than ever since recovery audit activities have proven to be effective in identifying and recouping payments for services that were not adequately documented.1,2 EMRs facilitate these audits by making health records so much easier to read. Payers are focused on their contractual obligations to pay for medically necessary treatment, but it is the provider’s responsibility to demonstrate the necessity of the services rendered. Ironically, handwritten records that were barely legible were often interpreted in the favor of the provider, but not any more.
The primary problem is that physical therapists have abandoned their responsibility for the contents of the medical record to application developers and software engineers. Your software is a sophisticated application, but it is built through a process: Subject matter experts in physical therapy practices write specifications that lead to development requirements, and these requirements lead to programming code, which ultimately results in the final software application—the associated database and the graphic user interface (GUI). Applications produce what you see on the screen in the form of the GUI. Databases house the data and can maintain the business logic and rules that govern how the system runs, makes decisions about inputs, and moves data.
The software that is eventually produced is the product of interpretation of detailed application requirements by software developers. The usability and effectiveness of meeting the various contractual and regulatory requirements of payers is the result of this process. Subtleties abound, and often the eventual end users (physical therapists) have faulty or incomplete understanding of the contractual and legal elements of establishing medical necessity. As a result, they overrely on EMRs to produce a compliant medical record that adequately demonstrates medical necessity.
EMRs are good at some things and not so good at others. Understanding the differences is the key to producing excellent documentation. Documentation applications establish and track the required elements of the medical record, making sure those requirements are completed, health information exchange and reporting, pushing data and charges to billing, and tracking clinical and health outcomes. They can force completion of compliance requirements and monitor timing guidelines. They can even be used to guide clinical decision making based on therapist inputs in comparison to clinical practice guidelines.
Requiring field elements to be filled out and electronically signed does not guarantee that physical therapists are producing adequate medical records to support the medical necessity of treatment. EMRs cannot provide patient-specific insights and analysis, demonstrate skilled care with clinical input, forecast outcomes and identify clinical expectations, or explain complex outlier results of interventions without targeted therapist input. In their quest to maximize efficiency and to offset the time required to write an adequate clinical note, physical therapists are often obsessed with templates and preloaded pages that they believe can apply to all patients with a particular diagnosis or clinical problem. The combination of non-patient-specific documentation can too easily create notes that do not adequately support skilled care based on individual patient needs.
Payers, referral sources, and health care stakeholders want to know four things about your patients:
- What did you do?
- Why did you do it?
- How is it helping and how do you know?
- How much more does the patient need and how much longer will it take?
Templates and selecting from pick-lists of words and phrases cannot answer these questions. Documentation specific to the patient’s condition and health demonstrating real-time therapist clinical decision making must exist.
What physical therapists need to accomplish in the medical record is to communicate the clinical reasoning they used to “connect to the dots” from impairments identified in the evaluation to interventions. They must adequately demonstrate the activity limitations/participation restrictions caused by the impairments that led to the decreased patient function with the proper subjective exam, as well as tests and measures shown to be reliable in a patient population representative of that specific patient. Then, finally, the goals for the episode of care that address the activity limitations/participation restrictions that can be measured and tracked with the proper tests and measures can be described.
Self-auditing and review of the quality of documentation has never been more important as part of your compliance strategy. This legibility of electronic documentation plus therapist penchant for template-driven EMRs is producing a phenomenon the payers refer to as note cloning. In note cloning, the daily treatment records, plans of care, and progress reports are nearly identical within a patient case and can be shockingly similar from patient to patient for patients treated by the same therapist. This problem is not unique to physical therapy; it is a common problem throughout health care.3
Numerous vendors and consultants who can perform simulated audits of your documentation quality are available. However, you should perform your own reviews, and your therapists should be involved in the process. Nothing will change a therapist’s documentation habits faster than having his or her documentation reviewed by his or her peers. American Physical Therapy Association (APTA) has produced a basic review template that can provide you with the start of an effective self-auditing tool, Defensible Documentation: www.apta.org/Documentation/DefensibleDocumentation. Use this tool as a starting point for creating your own self-audit tool.
To perform an audit, you will need to produce the complete medical record output from your software. Many therapists do not understand that the medical record is the output of the application, not what you enter into the application via the GUI. To appreciate the quality of their documentation, therapists need to review their records in their complete form, just as payers do. Self-auditing can effectively provide this opportunity.
Developing a culture of critical self-assessment of your clinical decision making and patient care documentation is critical. The evolution of the software tools that we use tempts us to offload our responsibilities for the content of the medical record to software developers. Be vigilant to hold yourself and your physical therapists accountable for their patient care as they represent it in the medical record. Do not be a surprised victim of denials and recovery audits. Take back control of your documentation quality from your software.
1. Recovery Audit Contracting: The Wave of the Future, Citizens Against Government Waste. http://cagw.org/media/wastewatcher/recovery-audit-contracting-wave-future. Accessed December 11, 2014.
2. Recovery Auditing in Medicare and Medicaid for Fiscal Year 2012, Center for Medicare and Medicaid Services. www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Report-To-Congress-Recovery-Auditing-in-Medicare-and-Medicaid-for-Fiscal-Year-2012_013114.pdf. Accessed December 11, 2014.
3. Templates, Ethics, and Chart Audits in Billing: The Journal of the Healthcare Billing and Management Association, Vol. 19, November/December 2014, Pages 8 through 10.
John Wallace, PT, MS, is a PPS member and the chief executive officer for BMS Practice Solutions Inc., in Upland, California. He can be reached at email@example.com.