by Tim Rowan, Editor
It is not possible to overestimate the benefits of completing clinical documentation in the presence of the patient. From initial assessments to daily visits to 12-hour shifts, the accuracy and thoroughness of what is written down is nearly as important as the quality of treatments administered. Catching up on paperwork at the end of a day or the end of a week has been proven to invite MAC, RAC and ZPIC attacks on Medicare certified healthcare at home providers and complaints from family members of harmed Private Duty patients. On the other hand, documenting while the memory is fresh increases accuracy and thoroughness, blocking most auditor and family complaints.
For years, these pages have nagged the industry and congratulated individual agencies about this issue. See our "Data Analysis Tool Identifies Home Care Patients Ready for Hospice" (8/12/15), for a mention of in-home documentation as a Michigan agency's absolute condition of employment and "Elite Team Builds Point-of-Care System for HEALTHCAREfirst" (9/30/15) about the efforts of one software vendor to build a point-of-care system designed to make it easier for clinicians to document in the patient's home.
Our conviction that clinical software systems should promote rather than inhibit in-home documentation is the reason we highlight software vendors when we see them making an effort. Hence, this week's publication of a Brightree press release about winning the business of a Texas provider largely because of its new iPad system that encourages in-home documentation. In vetting the press release, we were thrilled to discover that Brightree is promoting its new point-of-care system with the same evidential argument I have been using for years.
If you watch their web site video promoting the point-of-care iPad system, you will see some claims about the relationship between documentation accuracy and the length of time between patient encounter and completing documentation. You will not see, however, a citation for the source of these claims. So here is that citation that Brightree and I learned from the same source. It is a story worth repeating.
When I speak to healthcare at home audiences at state and national association meetings, I often retell a story I learned from Medicare compliance consultant Michael McGowan. Briefly, so the story goes, when OASIS was new, McGowan was OASIS Coordinator for the State of California. He held full-day seminars to introduce the new assessment rules to home health clinicians. As part of the training, he had learners complete OASIS assessments on him as the patient three times during the training: 8:00 am, noon, and 4:00 pm. Only during the first assessment would he answer questions about his fictional condition. The other two they had to do from memory.
After each session, answers were compared one to another in small groups. I have never seen more convincing evidence that the human memory is finite and that it fades rapidly over short periods of time:
I was happy to see these exact numbers cited in a promotional video on the Brightree web site this week. The reason, they say in the video, you should choose their iPad-based point-of-care system is because it facilitates charting during the visit instead of afterward and this improves accuracy. Whether the marketing claims are true is not the point for the moment -- although I have seen the Brightree iPad system and it does support compliance while still encouraging charting in the presence of the patient. The point, rather, is that it is encouraging to see more and more software developers recognizing and addressing the serious problem of late-night charting from memory.
Agency owners undoubtedly would like to establish a condition of employment that requires documentation to be completed in the presence of the patient but two obstacles have stopped them in the past. One was the nursing shortage, which is over, so that obstacle is out of the way. The other is management's understandable reluctance to demand adherence to a standard when they realize that the very software they provide to clinicians is what slows them down and interferes with them meeting the standard. Sometimes it's not the clinicians' fault.
Fatal Flaw: software that is too easy
Let's finish with a caution to software developers. It is possible to fall into a trap by going overboard with efforts to make clinical modules easy to use. Some vendors try so hard to be popular with clinicians that they give them what they want rather than what they need, and wind up compromising the agency's fiscal health. Let me explain, based on what I hear from Medicare home health attorneys and payment denial appeals consultants.
What clinicians need is software that helps them make accurate assessments, including complete and thorough OASIS documents; that guides them to build care plans based on assessments; and that facilitates accurate and compliant visit notes. What they want is to complete their documentation quickly and easily. Some software that focuses too much on quick and easy and too little on compliance allows clinicians to copy text from one visit and paste it into the record of the next visit, and so on, over and over again.
Many clinicians like this because of the time it saves them but agency owners and clinical supervisors should avoid at all costs software that allows this practice. In the Medicare world, there is no more direct route to payment denials and ADRs. One of the first things MAC and ZPIC auditors look for is identical language from one visit to the next. It is the easiest way for them to meet their denial quotas. When they find evidence of cut and paste in one chart, they want to see all your charts, looking for patterns. Patterns give them the opportunity to upgrade an abuse case to a fraud accusation.
Auditors are not interested in listening to you argue the difference between sloppiness and intent to fraud. It is all the same to them. Remember, CMS's long term goal is to reduce the number of certified agencies. MACs and ZPICs and RACs do not care which ones go down.
Admittedly, this is a touchy area, balancing between keeping staff happy and keeping auditors at bay. What you have to ask yourself is how happy would they be if their employer were to be shut down. Software with this fatal flaw is often cheaper, but it will cost you thousands more, perhaps millions more, in the long run.
©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org