MCOs shout: Show me the records!’ Can you deliver?
Integrated systems pose record review problems
Hospitals that operate outpatient facilities are wrestling with this question: How do we effectively coordinate external quality reviews of our outpatient records when the process involves a network of separate ambulatory centers?
Is it easier to have the outpatient records located in one central location? What if the records aren’t centralized and the insurer asks to see one of the files from one of our outlying surgery centers?
Outpatient managers at Harborview Medical Center in Seattle devised a solution by simultaneously centralizing and distributing a custom-made outpatient clinic record on computer.
The electronic files are actually extracts of the main patient record, containing information relating only to specific outpatient sites. An extract is stored electronically for each outpatient department or facility in the network. At Harborview, there are more than 60 outpatient departments and clinics.
Insurers can therefore ask to see any document from any clinic, and it can be quickly provided on-line, says Julia Henion, who oversees outpatient surgery as Harborview’s associate administrator for ambulatory care.
"The system isn’t a computerized patient record per se but an electronic extract taken from the main record and set up for each department," notes Henion.
The system was devised by the hospital’s management information department with the assistance of Henion’s staff and other outpatient department heads. It uses standard data management software to extract the outpatient information and format the data under a separate file. But it still is under careful scrutiny and hasn’t been perfected, Henion says.
Could lead to strong approval rating
Harborview is an example of how integrated providers around the country are finding ways to simplify outpatient record reviews. "Whatever you can do to simplify the process is to your advantage," observes Melissa H. Jarriel, RRA, director of medical records at the Medical College of Georgia Hospital and Clinics in Augusta.
Often, the innovations are simple but can contribute significantly to a strong approval rating on the day of the site visit, says Jarriel. (For a description of how insurers grade facilities on their record quality, see story, at left.) Here are five suggestions:
• Remember the essentials.
Requests for documentation can vary, says Susan Keane Baker, MHA, principal of Malpractice Prevention Seminars, a New Canaan, CT, medical documentation firm. But even on the outpatient side, reviewers will ask for essentials, including a clearly written problem list, operative reports, all visits within the past year, relevant diagnostic tests, prescribed medications list, and copies of the complete history and physical.
• Keep the reviewer informed.
But don’t stop there, Baker says. Inform the reviewer that there are other documents that pertain to the patient that were not made available but can be obtained if necessary. You may be volunteering more information than was requested, but in an integrated care setting, the reviewer needs to be reminded that the facility has several departments that have contributed to the patient’s medical care and reflect overall quality, Baker adds.
• Don’t rely on the clinic’s shadow charts.
Some providers rely inordinately on the contents of shadow charts, which usually contain photocopies of information relevant only to a specific clinic or department, says Jarriel.
Shadow charts serve a valuable purpose in instances when certain information turns up missing in the main record. But they offer at best only a partial picture of total patient care and can actually hurt a review due to their narrow scope. In addition, they’re becoming less dependable with the advent of the fully computerized record, adds Henion of Harborview.
• Work with the reviewer.
Inform the insurer that your facility does certain things differently. "Don’t leave it to them to figure it out," says Jarriel. For example, if your outpatient problem lists are kept exclusively on computer files and not in the paper charts, the reviewer will assume they’re missing. The matter became an issue at Jarriel’s facility until the managed care organization (MCO) was informed of the fact at a post-review meeting.
Include physician-signed copies
On another occasion, the MCO criticized the facility for failing to include copies of the physician-signed lab reports in the paper files. Managers later informed the reviewer that physicians typically reviewed the lab work on-line. Paper copies weren’t kept in the outpatient file.
• Select a strategic location.
It is pointless to schedule a review at the hospital when the outpatient records are kept at the clinics. Yet, many managers feel they can control the review at the main facility better, says Baker.
Even if the records can be hand-delivered anywhere, there may be requests for additional documents. Therefore, provide the reviewer with a telephone or a pager and a number to make such requests, Jarriel offers. The worst you can do is seem unprepared. "Appearing disorganized will hurt your appraisal," Baker says.
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