OHIMA Spring Conference, May 5 2006

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 don’t 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. Joseph’s, Hamilton highlight importance of coding • 78% of respondents have educated physicians about submission timeframes; most hospitals used memos • CIHI’s 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. John’s 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 >90% 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