Physician encounters should be long-term relationships, not one-night stands
Excellent read (link at conclusion of blog) about the misconceptions of Emergency Department care as primary episodic care, significant inroads are being made to integrate ED care with primary care. The key take away point for me in the article is the following:
Better communication naturally ties into better collaboration. Every visit, diagnosis, allergy, prescription and more has the potential to radically change how a physician interacts with a patient.
In my continued quest to provide feedback to physicians on best strategies for enhanced communication of patient care focusing upon medical necessity denials, I notice a common theme, ineffective communication within the record, particularly when consultants are on board. There appears to be little collaboration between physicians on the case attributable to insufficient communication. The attending is not driving the ship, tying all the clinical information, facts and context together in a concise, consistent, clear and contextually correct patient story with the ability of the reader to find the patient within the story. As a result, each progress note does not lend itself to supporting and describing, showing, telling, depicting and reflecting a clear patient story. Progress notes don’t clearly and accurately reflect the clinical progress of the patient, it is hard to identify and determine whether the patient is clinically getting better, staying about the same, or worsening. When you read the physician orders, the reader attains a better understanding of how the patient is faring, distinctly different from the progress note which is devoid of any or little documentation summarizing clinical changes and the initiation of plan of care changes. It is simply not enough for the CDI specialists to clarify a diagnosis and equate this to documentation improvement and integrity. An accurate and complete telling of the patient story entails recording a clearly updated interval history that includes any clinical changes that manifested from the time of the last visit the previous day, any new complaints or issues as stated by the patient, what is wrong with the patient, how does the patient look and how did it manifest. This interval history is instrumental in updating the patient story, painting a clear snapshot picture that accompanies and supports the physical exam and clinical impression with plan of care. The patient story as recorded must flow logically and be easily read and understood by all physicians and other healthcare stakeholders participating in the care of the patient including case management and utilization review staff who are totally dependent upon the quality and completeness of the communication of patient care to execute their roles and duties for the patient and physician. Indisputably, effective communication of patient care facilitates effective collaboration supporting ideal outcomes and the optimal integrity of the revenue cycle.
Achieving Communication with Collaboration
Achieving communication of patient care that facilitates and fosters collaboration with strong outcomes requires the recognition and initiation of action to break down silos. An ideal place to start is for case management and utilization review to work together synergistically as one, strategizing and acting in a unified manner to drive improvement in documentation and communication of patient care. A unified manner involves promoting, advocating and achieving solid communication through creation of a vision and message that inspires physicians to understand and appreciate that the record represents a communication tool for both fellow physicians and the patient, allowing the entire care team to carry out the best possible cost-effective quality focused patient outcomes based fully informed coordinated care. At the end of the day, the record should tell the patient story in enough detail for the next physician assuming care of the patient to be able to quickly review the record and assume the patient care in an efficient manner without having to read the entire record and perform a History and Physical all over again. CDI collaborating with case management and utilization review means so much more than providing the working DRG and length of stay on a daily basis, this does little to advance the communication of patient care, instead it constitutes another statistic that CDI is forced to contend with as one of our many query-based metrics. I highly recommend as the first step in breaking down silos in CDI is for profession to take the lead in improving their understanding and recognition of what constitutes sufficient quality documentation that then can be used as a basis for educating physicians and case management/utilization review staff alike on the mechanics of effective communication of patient care. Without this understanding and knowledge of proper and complete documentation, CDI will continue to work in silos chasing diagnoses, merely clarifying what already exists in the record versus the preferred methodology of collaborating with physicians and other healthcare stakeholders to achieve real improvement in communication of patient care for all the right reasons. Let’s overcome the laissez-faire non-interventional approach that currently exists in CDI maintained by the overreliance on the query process.