Targeted audits have found a high percentage of inpatient rehabilitation facilities (IRFs) did not comply with Medicare coverage and documentation requirements over the past several years. A recent report released from the Office of Inspector General (OIG) concluded an 80% error rate was found through a stratified random sample chart audit of 220 IRF claims. The estimated financial impact of this report was $5.7 billion for care to beneficiaries that was not reasonable and necessary.
Mahesh Ramachandran, MD, and Vanessa Flaherty, PT, DPT, discuss their project titled, “Improving Quality of Physician Documentation in the IRF Setting,” which was presented at an American Medical Rehabilitation Providers Association event. They share that the goal is to improve the quality of physician documentation as it relates to the inpatient rehabilitation documentation guidelines and regulations by achieving the percent of charts compliant with all IRF Medicare documentation requirements to 100%.
Selected Podcast
Improving Quality of Physician Documentation in the IRF Setting
Featured Speakers:
Vanessa Flaherty, PT, DPT, is the Manager, Post-Acute Assessments at Northwestern Medicine Marianjoy Rehabilitation Hospital
Mahesh Ramachandran, MD | Vanessa Flaherty, PT, DPT
Dr. Ramachandran is the Chief medical Officer at Marianjoy. He is board certified in both physiatry and internal medicine, and his medical practice addresses the medically complex needs of rehabilitation patients. Dr. Ramachandran completed his medical training at the Chicago Medical School (now Rosalind Franklin University) after receiving his undergraduate degree at the University of Illinois in Urbana-Champaign. He was chief resident during his residency in physical medicine and rehabilitation at Loma Linda University & Medical Center in California. Dr. Ramachandran completed his internal medicine residency at the University of Illinois at Urbana-Champaign in 1998. Dr. Ramachandran's practice style is a reflection of his holistic approach to patient care, as well as his commitment to treating each individual with respect, empathy and compassion.Vanessa Flaherty, PT, DPT, is the Manager, Post-Acute Assessments at Northwestern Medicine Marianjoy Rehabilitation Hospital
Transcription:
Improving Quality of Physician Documentation in the IRF Setting
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today I invite you to listen in as we discuss improving the quality of physician documentation in the IRF setting.
Joining me in this panel is Dr. Mahesh Ramachandran, he's the Chief Medical Officer at Northwestern Medicine's Marianjoy Rehabilitation Hospital, and Vanessa Flaherty, she's a physical therapist and the Manager of Post-Acute Assessments at Northwestern Medicine's Marianjoy Rehabilitation Hospital. Thank you both for joining us today,
Dr. Ramachandran, I'd like to start with you. You recently presented a project titled Improving Quality of Physician Documentation in the IRF Setting at the American Medical Rehabilitation Providers Association. Can you tell us a little bit about this project and what was the goal?
Dr Mahesh Ramachandran: Sure. The project was about improving the documentation in any patient that was admitted to our inpatient rehabilitation facility at Marianjoy. For IRFs or inpatient rehab facilities, there are certain mandatory documentations that the physician has to provide on each particular patient. Some are time-based and some are content-based.
As we change into a new system with regards to an electronic medical system, the processes were changed for all the physicians on how to properly document these mandatory situations. And myself and Vanessa, along with a whole team of IT professionals as well as physicians, started a process improvement project to help ensure that we're compliant with these mandatory regulations.
Melanie: Well then, Dr. Ramachandran, how did you evaluate these issues?
Dr Mahesh Ramachandran: So there were about three or four of these mandatory regulations. We took them each separately and looked at physician's workflow and how these regulations could be compliant with physician's workflow using physician input as well as the collaboration with the IT professionals to make a system in a situation as easy as possible, so that compliance could be assured.
Vanessa Flaherty: And I'll tag onto Dr. Ramachandran's comment there and add that, at the start of this project, we really identified that there was a lack of a standardized audit process to better understand Marianjoy's performance in regards to documentation of these specific requirements. So, in knowing that, we developed a very specific inpatient rehab documentation audit tool and worked alongside our health information colleagues to begin to collect metrics on all of the patients and providers.
And it really allowed us to understand all the opportunities to improve the quality of our documentation as it results to documenting IRF-specific medical necessity criteria. So we really use this as an opportunity to design our documentation at the highest standard and identify all areas that we can look to improve and become more effective and efficient.
Melanie: Well then, Vanessa, I'd like you to expand a little bit. What did this project uncover and what solutions did you derive from your work?
Vanessa Flaherty: Yeah. As we dug into what Marianjoy's current performance was demonstrating, we really uncovered that there were some primary areas of focus to improve our overall documentation quality. The first being an education gap, really having the providers understand the requirements, and the time-based requirements specifically, as well as Dr. Ramachandran had mentioned the content requirements, so what we need to have within our documentation to fully support an admission and a stay in the IRF setting.
And then we also identified that there was a lack of a standardized process for completing these requirements. So how can we, as Dr. Ramachandran had mentioned, make a workflow that really worked with the physician and made it so that we reduced burden whenever possible and created a really efficient way to complete these requirements?
And then lastly, but most importantly, the main focus was uncovering that there really was ineffective functionality within our current EMR builds. So what can we do to better design and mold the EMR to work in our benefit?
Melanie: Dr. Ramachandran, are there learnings you think are relevant to other inpatient rehabilitation facilities? If you were speaking to them, what would you tell them about what you've learned in the importance of adequate physician documentation?
Dr Mahesh Ramachandran: Absolutely. I do think from this project that we can impart a lot of knowledge. When we set up this EMR profile, you need a lot of collaboration. First and foremost, you do need physician input. They're the ones who are the end users. They are going to be using this system. So you need physician input on what makes it work as easy and as efficient as possible for them. You need compliance officials to be making sure that all the regulations are correct and appropriate and so that the EMR can adapt and be compliant with those regulations. Certainly, you need collaboration from your IT professionals as they're building the EMR to make sure that it is user-friendly and conducive to the physicians as well.
So I think the biggest learning point is this collaboration is very important. One area cannot build this project. It needs a collaboration of all three with input from all three. So it can make it, number one, user-friendly; number two, efficient; and, number three and most important, compliant and then which will impart better patient care for our patients.
Vanessa Flaherty: And I'll tag onto that and add a little bit of specific detail around how through this project we made that collaboration happen. One of our primary solutions in the project was an EMR optimization plan that was spearheaded by a specifically assigned work group.
So as Dr. Ramachandran had mentioned, we really needed to get the rehab physician involved in this planning and development. So we developed a collaborative that we call the rehab physician documentation collaborative. And we had very structured and frequent meetings and we continue after this project has been completed to meet to allow discussion for the most optimal build within the EMR to allow the highest quality of documentation.
So this really allowed for collaboration between physicians and all of the other appropriate team members to bridge that gap between optimal physician workflow, regulatory concerns, and EMR capabilities.
Melanie: Vanessa, from the perspective of post-acute assessments, how do you see this transferring to better patient care? Dr. Ramachandra and touched on it. And I'd like for you to expand it as you're right there with the patients every day, how is this going to help them and make things more streamlined and understandable for them?
Vanessa Flaherty: Absolutely. So of course, within any medical setting, the constant communication between all members of the care team is crucial and that happens in person, through meetings, et cetera, but what stays and lives with the patient is the medical record, is that documentation. So through the work of this project, we really better understood the onus of the rehab physician in documenting the rehab plan of care and all of the specifics of the patient's clinical picture to allow us to understand what we need to do to improve the patient and to get them discharged home safely and overall just improve their function.
And really, I think that this project uncovered how we can better improve the quality of the documentation we are putting within the record to demonstrate all of the specific needs, improvements, limitations, barriers of the patient. And that was really success of the project and really lends itself to improving how we treat our patients and really putting our patients first.
Dr Mahesh Ramachandran: I'd like to add on to what Vanessa said. All of that is absolutely true. And in addition, when we talk about collaboration of building an EMR, rehabilitation is about collaboration between many disciplines. So with insurance of that documentation and all the disciplines understanding how we're working towards one specific goal, whether it's rehabilitation nursing, rehabilitation therapy, psychology, as well as the medical component from the physician. When that documentation is done correctly and appropriately and in a timely manner, the whole team can understand the specific goals for the patient, how we're reaching those goals, so we can get the maximum functional improvement for those patients.
Melanie: Well, Dr. Ramachandran, I'd like to give you the last word here. What else would you like physiatrists to know about this topic, and advice for others looking to optimize their documentation at their organizations?
Dr Mahesh Ramachandran: Absolutely. I think that having an EMR, even though in the beginning, there is a learning curve into using an EMR, but if the EMR is done correctly and appropriately, it can really enhance how efficient you are, but much more importantly, as we talked about, improve patient care and outcomes.
And that's the bottom line. That's why we're in the field of rehabilitation, is to make sure our patient patients. get the maximum functional improvement with our care. And I think an EMR can be essential in helping achieve that.
Melanie: Vanessa, do you have any final thoughts that you'd like to share with other providers?
Vanessa Flaherty: I would say one thing I took away personally being a non-physician was the fact that it is so critical and important to gain that physician engagement when working on any sort of project that involves them as a stakeholder and by allowing them to be a part and truly drive the change within their workflows and documentation, that's how we truly saw such a success with the project's outcomes.
Melanie: Thank you both for joining us today. And to refer your patient or for more information, please visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.
Improving Quality of Physician Documentation in the IRF Setting
Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today I invite you to listen in as we discuss improving the quality of physician documentation in the IRF setting.
Joining me in this panel is Dr. Mahesh Ramachandran, he's the Chief Medical Officer at Northwestern Medicine's Marianjoy Rehabilitation Hospital, and Vanessa Flaherty, she's a physical therapist and the Manager of Post-Acute Assessments at Northwestern Medicine's Marianjoy Rehabilitation Hospital. Thank you both for joining us today,
Dr. Ramachandran, I'd like to start with you. You recently presented a project titled Improving Quality of Physician Documentation in the IRF Setting at the American Medical Rehabilitation Providers Association. Can you tell us a little bit about this project and what was the goal?
Dr Mahesh Ramachandran: Sure. The project was about improving the documentation in any patient that was admitted to our inpatient rehabilitation facility at Marianjoy. For IRFs or inpatient rehab facilities, there are certain mandatory documentations that the physician has to provide on each particular patient. Some are time-based and some are content-based.
As we change into a new system with regards to an electronic medical system, the processes were changed for all the physicians on how to properly document these mandatory situations. And myself and Vanessa, along with a whole team of IT professionals as well as physicians, started a process improvement project to help ensure that we're compliant with these mandatory regulations.
Melanie: Well then, Dr. Ramachandran, how did you evaluate these issues?
Dr Mahesh Ramachandran: So there were about three or four of these mandatory regulations. We took them each separately and looked at physician's workflow and how these regulations could be compliant with physician's workflow using physician input as well as the collaboration with the IT professionals to make a system in a situation as easy as possible, so that compliance could be assured.
Vanessa Flaherty: And I'll tag onto Dr. Ramachandran's comment there and add that, at the start of this project, we really identified that there was a lack of a standardized audit process to better understand Marianjoy's performance in regards to documentation of these specific requirements. So, in knowing that, we developed a very specific inpatient rehab documentation audit tool and worked alongside our health information colleagues to begin to collect metrics on all of the patients and providers.
And it really allowed us to understand all the opportunities to improve the quality of our documentation as it results to documenting IRF-specific medical necessity criteria. So we really use this as an opportunity to design our documentation at the highest standard and identify all areas that we can look to improve and become more effective and efficient.
Melanie: Well then, Vanessa, I'd like you to expand a little bit. What did this project uncover and what solutions did you derive from your work?
Vanessa Flaherty: Yeah. As we dug into what Marianjoy's current performance was demonstrating, we really uncovered that there were some primary areas of focus to improve our overall documentation quality. The first being an education gap, really having the providers understand the requirements, and the time-based requirements specifically, as well as Dr. Ramachandran had mentioned the content requirements, so what we need to have within our documentation to fully support an admission and a stay in the IRF setting.
And then we also identified that there was a lack of a standardized process for completing these requirements. So how can we, as Dr. Ramachandran had mentioned, make a workflow that really worked with the physician and made it so that we reduced burden whenever possible and created a really efficient way to complete these requirements?
And then lastly, but most importantly, the main focus was uncovering that there really was ineffective functionality within our current EMR builds. So what can we do to better design and mold the EMR to work in our benefit?
Melanie: Dr. Ramachandran, are there learnings you think are relevant to other inpatient rehabilitation facilities? If you were speaking to them, what would you tell them about what you've learned in the importance of adequate physician documentation?
Dr Mahesh Ramachandran: Absolutely. I do think from this project that we can impart a lot of knowledge. When we set up this EMR profile, you need a lot of collaboration. First and foremost, you do need physician input. They're the ones who are the end users. They are going to be using this system. So you need physician input on what makes it work as easy and as efficient as possible for them. You need compliance officials to be making sure that all the regulations are correct and appropriate and so that the EMR can adapt and be compliant with those regulations. Certainly, you need collaboration from your IT professionals as they're building the EMR to make sure that it is user-friendly and conducive to the physicians as well.
So I think the biggest learning point is this collaboration is very important. One area cannot build this project. It needs a collaboration of all three with input from all three. So it can make it, number one, user-friendly; number two, efficient; and, number three and most important, compliant and then which will impart better patient care for our patients.
Vanessa Flaherty: And I'll tag onto that and add a little bit of specific detail around how through this project we made that collaboration happen. One of our primary solutions in the project was an EMR optimization plan that was spearheaded by a specifically assigned work group.
So as Dr. Ramachandran had mentioned, we really needed to get the rehab physician involved in this planning and development. So we developed a collaborative that we call the rehab physician documentation collaborative. And we had very structured and frequent meetings and we continue after this project has been completed to meet to allow discussion for the most optimal build within the EMR to allow the highest quality of documentation.
So this really allowed for collaboration between physicians and all of the other appropriate team members to bridge that gap between optimal physician workflow, regulatory concerns, and EMR capabilities.
Melanie: Vanessa, from the perspective of post-acute assessments, how do you see this transferring to better patient care? Dr. Ramachandra and touched on it. And I'd like for you to expand it as you're right there with the patients every day, how is this going to help them and make things more streamlined and understandable for them?
Vanessa Flaherty: Absolutely. So of course, within any medical setting, the constant communication between all members of the care team is crucial and that happens in person, through meetings, et cetera, but what stays and lives with the patient is the medical record, is that documentation. So through the work of this project, we really better understood the onus of the rehab physician in documenting the rehab plan of care and all of the specifics of the patient's clinical picture to allow us to understand what we need to do to improve the patient and to get them discharged home safely and overall just improve their function.
And really, I think that this project uncovered how we can better improve the quality of the documentation we are putting within the record to demonstrate all of the specific needs, improvements, limitations, barriers of the patient. And that was really success of the project and really lends itself to improving how we treat our patients and really putting our patients first.
Dr Mahesh Ramachandran: I'd like to add on to what Vanessa said. All of that is absolutely true. And in addition, when we talk about collaboration of building an EMR, rehabilitation is about collaboration between many disciplines. So with insurance of that documentation and all the disciplines understanding how we're working towards one specific goal, whether it's rehabilitation nursing, rehabilitation therapy, psychology, as well as the medical component from the physician. When that documentation is done correctly and appropriately and in a timely manner, the whole team can understand the specific goals for the patient, how we're reaching those goals, so we can get the maximum functional improvement for those patients.
Melanie: Well, Dr. Ramachandran, I'd like to give you the last word here. What else would you like physiatrists to know about this topic, and advice for others looking to optimize their documentation at their organizations?
Dr Mahesh Ramachandran: Absolutely. I think that having an EMR, even though in the beginning, there is a learning curve into using an EMR, but if the EMR is done correctly and appropriately, it can really enhance how efficient you are, but much more importantly, as we talked about, improve patient care and outcomes.
And that's the bottom line. That's why we're in the field of rehabilitation, is to make sure our patient patients. get the maximum functional improvement with our care. And I think an EMR can be essential in helping achieve that.
Melanie: Vanessa, do you have any final thoughts that you'd like to share with other providers?
Vanessa Flaherty: I would say one thing I took away personally being a non-physician was the fact that it is so critical and important to gain that physician engagement when working on any sort of project that involves them as a stakeholder and by allowing them to be a part and truly drive the change within their workflows and documentation, that's how we truly saw such a success with the project's outcomes.
Melanie: Thank you both for joining us today. And to refer your patient or for more information, please visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.