Physicians and medical centers touting “best outcomes” are increasingly getting a direct question back from third party payers and the consortiums and associations that rate hospitals:

“Can you prove it?”

Organizations such as the JCAHO, the corporation-sponsored Leapfrog Group, and certainly insurance companies are demanding objective information about quality and patient outcomes.

“The quality and rigorousness of the answers SHC provides have huge implications in terms of reimbursement, selection of centers of excellence, recruitment of faculty, and finally, the ability to prove to patients - who are scrolling through websites seeking this information - that Stanford should be their medical center of choice,” explained Associate Chief of Staff Joseph Hopkins, who chairs the Quality Improvement and Patient Safety Committee.

“The JCAHO will be here in 2007 under a new program of unannounced inspections. The reality is that we must have our systems in place simply to remain accredited - but there is some sunlight in this process. The changes occurring now from clinical analytics and other information systems improvements are actually providing all of us as physicians with information that is making practice safer, easier and more efficient - at least at the end of the day,” said Hopkins.

A new breed of professional is increasingly responding with tools, techniques and other analytical resources that use objective data provided by physicians, other health care workers and the institution itself. The buzzwords are outcomes research, and clinical analytics but the tools it relies on are as familiar as ICD codes and precise chart entries.

“Everybody at Stanford wants Stanford and their own programs to be the best, but the only way we can show that is to have the information right in front of us,” said Trent McLaughlin, a pharmacist with a PhD in pharmacoeconomics (no, it’s not in most dictionaries). Since last October, McLaughlin has headed SHC’s new Department of Clinical Analytics & Outcomes. The staff, in addition to McLaughlin, includes a statistician and two clinical informatic analysts.

The department has worked closely in a pilot project with the Cardiothoracic Surgery Department to gather objective outcome data that in March was included in the first quarterly report providing detailed outcomes data, including length of stay, mortality, readmission and complication rates specific to common procedures.

Following the CT surgery pilot, clinical analytics are being implemented in neurosciences, orthopedics, oncology and transplantation, but McLaughlin and Hopkins expect the program to expand institutionwide.

The data are expected to be compared with similar peer institutions and provided as requested to the Joint Commission on the Accreditation of Healthcare Organizations, University Hospital Consortium, Leapfrog Group and California’s Office of Statewide Health Planning & Development.

“We are really hoping that this data will become an important tool for physicians,” McLaughlin said. “We need to hear from physicians about what metrics are most useful to them as we expand the services we are able to provide. We can provide customized reports that may answer questions that services need answered. We can be a resource at solving puzzles.”

McLaughlin said in the coming months he expects that his department will be able to work with personnel across the institution to produce a wide range of comparative outcome results for all inpatient and outpatient services.

McLaughlin and Mirzet Halilovic, a physician who serves as SHC’s manager for Coding and Data Reporting, both say that a key to providing information that will ensure appropriate reimbursement, disclose outcomes in both high and lower acuity environments, and provide nationally valid feedback, is for physicians to provide complete medical documentation that meets a variety of rigorous - and changing - coding standards.

“The reality is that physicians are very busy - being pulled in all directions to meet the demands and expectations of patient care. Everyone has to learn in his or her own way how to document based on current regulations,” said Halilovic.

Halilovic said that coders need help in at least two care areas: insufficient documentation and insufficient data to describe the complexity of care required to justify length of stay. Complete documentation will ensure that SHC’s picture as a tertiary center treating more complex patients is accurately portrayed - and that the institution is fairly reimbursed for the type of care provided.

“Coders can’t make assumptions - they have, are and will be contacting physicians when they have questions, and there are a few key steps that busy doctors can take to help the process move more efficiently. We have identified key points that coders are too often finding missing - and which we must have to provide quality information, including feedback to physicians.

Here is a checklist of items that the coders frequently find missing or unclear, requiring a call back to the physician:

Written progress note
Written OP Note in chart in addition to dictation
Proper History & Physical (stating reason for admission)
Suspected diagnosis named when ordering a test
Principal Diagnosis and Secondary Diagnosis not conforming to current clinical guidelines
Co-morbid conditions and/or complications (CC) - These help describe complexity of the patient’s care, justify length of stay (care), and increase case mix index (CMI)
Discharge Summary – Please summarize all facts pertaining to diagnostics and treatment as well as naming all treated diseases and conditions during encounter.

** Please respond to coder inquiries **

And to make sure that documentation is as complete as possible, Halilovic has summarized these rules:

Characteristics of Good Documentation

LEGIBILITY: Illegible documentation can trigger denial of payment for services as well as provoke possible quality issues with the care of the patient.

COMPLETENESS: To determine completeness of documentation, ask the following questions:

Does the information flow logically?
Are there any information gaps?
Are there abnormal test results without explanatory documentation?
Is there conflicting documentation in the patient record?
Are there any required reports that are missing?

Timeliness is prescribed by regulations and laws. For example, certain documents need to be in the patient’s record within 24 or 48 hours. Other clinicians may potentially need the information.

AUTHENTICATION: Physicians’ (and other clinicians treating the patient) signatures are required on all their own documentation. As well, physicians need to co-sign and often document more detailed information along with documentation for other clinicians whose work they are responsible for, including housestaff.

McLaughlin, Halilovic and their staff will be contacting physicians and their departments as the clinical analytics and various coding improvement efforts move forward. But both professionals said they would like to hear from physicians with questions or suggestions:

McLaughlin can be reached at: tmclaughlin@stanfordmed.org
Halilovic may be contacted at: mihalilovic@stanfordmed.org