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Curbside Consult with Dr. Jayne 8/31/15

August 31, 2015 Dr. Jayne 2 Comments


A reader recently contacted me about strategies for dealing with providers that are struggling with chart completion:

My outpatient physician group is struggling with chart completion after conversion to an EHR. Some physicians have no issues, but others are having considerable problems. Not surprisingly, the ones struggling are the same physicians who had trouble on paper and had stacks of charts in their offices before EHR. Our policy is that charts need to be completed within two days. However, we have physicians who have hundreds of charts open and are months old and therefore not billed.

We are considering a policy that states charts over two weeks old will result in fines, which is similar to one of our competitors. We are estimating over $100,000 of accounts receivable that we will not be able to collect due to the age of the charts. There is another $25,000 in incomplete charts being added on a weekly basis. I wonder if any of your readers can share their approach.

The reader wanted to remain anonymous, which shouldn’t be hard because there are probably hundreds of organizations in this same position. I’ve personally worked with dozens of them.

Ideally, this problem is best addressed while the organization is still on paper. This allows leadership to get a handle on undesirable behaviors without physicians blaming the EHR. I can count on one hand the number of physicians I’ve seen who were delinquent on paper charts but got faster with the addition of an EHR, so confronting it head on is the best way to handle it.

Unfortunately, many organizations don’t have the resources to optimize their workflows before implementing an EHR. This leads to one of two things: either the EHR implementation team is forced to deal with problems and behaviors that are potentially outside their area of expertise or the behaviors simply don’t get addressed and the EHR takes the blame.

Like the reader, many organizations are motivated to action when the delays start to impact the revenue cycle and some let it get significantly out of control. The last client I helped with this problem had almost $6M in unbilled encounters before they realized they had a problem. Needless to say, they also had other revenue cycle issues which led to it getting that bad.

Meaningful Use throws another wrench into this process, particularly with the need for eligible providers to send out clinical summaries with pertinent information within a set number of days. Although some organizations go ahead and send out the incomplete summaries (a reader shared his or her own story with Mr. H) others hold the summaries which will cause the provider to fail attestation if they can’t meet the threshold.

Generally most approaches to this problem fall into either the carrot or stick categories. In the incentive space, physicians may receive cash bonuses for timely documentation or receive advantages in the creation of on-call schedules or vacation requests. Although some physicians (particularly ones earlier in their careers or with young families) respond well to this, not everyone cares about extra money or call schedules. Some physicians also aren’t motivated by the desire to get information to patients in a timely manner (via MU-required clinical summaries) either, so that may be off the table.

When organizations decide to employ a stick, usually it is a financial one. My residency program did this to the faculty and it was successful. (The residents had their grades withheld if charts were delinquent, so they weren’t a problem.) Charts older than five business days resulted in a fine, which came directly out of the faculty member’s paycheck. It took months to get it set up with the accounting and payroll departments and the physicians had to sign a contract addendum agreeing to it. The faculty did it grudgingly and most of them waited until the last hour, but at least the charts stayed current.

Another group I worked with also made it contractual. Physicians had to meet chart-completion standards in order to be eligible to receive a bonus. They also had to use the EHR in a prescribed way (entering data discretely rather than free texting) in order to reach the bonus round. Bonuses were then calculated based on clinical quality measures, patient satisfaction scores, and a couple of other factors. It was successful because it could completely block the physicians from getting any bonus at all, but again took a contract amendment to give it teeth.

I’ve seen two clients hire scribes for physicians that had documentation issues. Whether or not they charged the cost of the scribes back to the physician depended on the physician’s impact on the bottom line. For example, a high-volume surgeon who was bringing in millions of dollars in revenue was not charged for the scribe because the money recouped from non-delinquent charts more than paid for the extra overhead. At another group, a primary care physician who swore up and down that the EHR was at fault was charged for the cost of the scribe because all of his partners were getting their charts done on time and were unwilling to subsidize or reward his lack of compliance.

This does come up in my consulting practice all the time, so I’m also interested in hearing other approaches. If someone has a great way to do it that doesn’t require a major overhaul of dozens (if not hundreds) of employment agreements I’d love to hear it.

How do you deal with delinquent charts? Email me.

Email Dr. Jayne.

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Currently there are "2 comments" on this Article:

  1. Yes, this is a common problem faced by many organizations, particularly those organizations in which the physicians control the power balance. It’s typically only reversed by a very stern and well-respected Medical Records Director pushing for documentation accuracy and timeliness or by a concerted effort from organizational leadership to reduce the number of Accounts Receivable days directly attributed to deficient charts.

    The EHR itself can complicate the debate because documentation policies often are not specific enough to address the EHR workflows. For example, the policy might say that a History & Physical note needs to be written within 24 hours of a patient’s arrival, but it might not address when that note needs to be signed. The physician could dictate the note, which would then get transcribed by a transcriptionist, and the physician would receive the note back in his/her InBasket or some type of work queue. Sometimes providers will neglect to work this list of transcriptions to sign, so the documentation remains incomplete for a long period of time. Other times a physician might begin the note, but walk away or “pend” the note before completing it. This can create another overdue backlog.

    Physicians willing to document directly into their EHR rather than dictate (unless their organization utilizes a dictating tool such as Dragon to transcribe to text in the EHR in real-time) will likely cause less documentation backlogs. Of course there is a learning curve if the physician is switching from a paper system or has always dictated in the past.

    As for carrot/stick approaches, there are a few other solutions. In addition to the financial penalties and bonus incentives you have mentioned, some organizations’ policies include a penalty of suspended admitting, attending, and scheduling privileges in the EHR. If a physician cannot see patients (and the organization remains firm), he/she will be more likely to complete the documentation by the set deadlines. There are even tales of organizations suspending physicians’ preferred parking or cafeteria privileges!

  2. Anyone who has worked in a group setting at a scale of more than a handful of docs has seen this problem. A couple of points:

    –the workflow/ process impacts of paper charts sequestered in this way flow downstream in so many ways more than just the financial. EHR’s ubiquity mitigate this impact greatly, but…

    –there are clinical implications to incomplete charting. Even when a patient encounter deserves a considered narrative, carefully articulated, the plan of care needs documentation, so others on the team can pick up on untoward events or patient questions.

    That last point is perhaps the foremost: clinical care is increasingly a team sport. At its best, it probably always has been. Persistent behaviors of the kind described reflect more than just habits.

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