Forum Focus – Bridging the gaps in effective communication (part one of a two-part series)

By Bill O’Neill, Director of Outreach and Communications for  the Center for Personalized Education for Physicians

The Physician Leadership Forum’s white paper, Lifelong Learning: Physician Competency Development, examines the ACGME/ABMS core competencies and identifies gaps between the perceived importance of each competency and the evidence that each is put to work in the hospital. The gap between importance and evidence was particularly apparent in one area: Interpersonal and Communications skills.

Everyone can agree on the importance of effective information exchange and the ability to work cooperatively in a health care team, but is everyone willing, or able, to devote the time and effort required for success in those areas? Evidence suggests there is still work to do. This article is the first of a two-part series, and will deal with the effective exchange of information on medical teams. While common pitfalls will be described, the real focus will be on improvement approaches for individuals, as well as strategies leaders can employ to create cultures of meaningful communication.

Effective Information Exchange via Effective Documentation

For the most part, effective information exchange in the hospital setting is accomplished through appropriate charting and record keeping. “Done well, documentation should serve multiple purposes: improving quality of care, patient safety, and institutional finances all at the same time,” said Dr. Joel Dickerman, Chief Medical Officer at Community Care in Colorado Springs, Colo. According to Dr. Dickerman, positive financial outcomes and effective documentation often go hand in hand. “Effective documentation contributes to effective transition of care, which in turn leads to reduced readmission rates and increased patient satisfaction – both metrics that improve patient care and reduce non-beneficial care,” he said.

Have Electronic Medical Records (EMR) Helped?

According to Dr. Dickerman, EMR systems do not always live up to their promise. If these systems are simply used to improve legibility and capture procedures and charges, they are not being utilized to their full potential. “EMR systems are tools, not solutions by themselves. Documentation should be viewed as a form of communication, not just a means of capturing charges and minimizing liability,” he said.

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, feels the structure of some EMR systems may contribute to this problem. “EMR systems do a good job capturing charges and documenting that various quality measures are being implemented (asking about smoking status, blood sugar control, etc.). Unfortunately, this can make a smooth narrative of patient care hard to find – and that can be problematic when there is a transition of care,” he said. As a result, he adds, “the architecture of these systems needs to evolve, making sure that clear, intuitive provider-to-provider communication is front and center in these systems.”

Never Enough Time…

Participants in CPEP’s Medical Record Keeping Seminar report that the biggest roadblock they face in improving documentation is time – a precious commodity in short supply. In addition to proactively building documentation time into the clinical schedule, Dr. Dickerman, the seminar’s program director, suggests hiring medical scribes as an effective approach. “The additional patients you see will more than pay for the service and allow you to be a doctor – not a typist,” he said. The American Health Information Management Association has a resource page devoted to medical scribes at http://bit.ly/145Gs36.

Strategies for Hospital Leaders – How to Improve Documentation at the System Level

Dr. Dickerman hypothesizes that the advent of value-based reimbursement may change the picture with its greater emphasis on quality of care, highlighting the value of effective documentation. He notes, however, “Some physicians may need to relearn lessons in professionalism and communication in such an environment.”

One way to encourage a new outlook on these issues is to put systems in place in which hospital and physician incentives are well aligned. While some hospitals are now reimbursed on a population health management basis, the physicians within those organizations may still be reimbursed on a volume-based, fee-for-service model. Improving the alignment of hospital and physician incentives will encourage physicians to view medical record keeping as an opportunity for ensuring and improving patient care rather than as a series of check boxes and drop-down menus that document individual procedures.

Dr. Katie Richardson, Director of Physician Experience at the Colorado Permanente Medical Group, notes, “At Kaiser Permanente, we’re incentivized to do what’s right for the patient, and our success is measured by the quality of our care, not by our productivity. We have medical informatics and communications teams that work closely together on training in oral and written communication/documentation, and the training is done almost exclusively by physicians. What’s more, our documentation skills are reviewed annually by our local physician leaders to ensure that each of us is communicating clearly with colleagues as well as patients in the After Care Summary – a Core Measure of meaningful use requirements.”

The Road Ahead: Transparency for Patients

In separate interviews, Kaiser Permanente’s Richardson and Mayo Clinic’s Wald independently noted the new reality of patients’ access to their data, and the subsequent demand for clear and cogent documentation. Dr. Wald notes, “Traditionally, the ultimate goal of EMR systems was clear communication with colleagues, ensuring smooth transition of care. More and more, however, patients demand greater access to their information and so clear documentation needs to speak to them as well.” Dr. Richardson concurs, “Full transparency of medical records with our patients is coming. As patients gain full access to their information, the responsibility for creating clear and meaningful stories of care will only grow more acute.”

Conclusion

The effective exchange of information through appropriate record keeping is a challenge for individuals and institutions alike. However, access to available educational resources, combined with innovative strategies driven by committed physician leadership can improve quality of care, reduce the risk of medical error and make measurable improvements to the financial health of health care institutions.

About the Author

Bill O’Neill is Director of Outreach and Communications for CPEP, the Center for Personalized Education for Physicians (www.cpepdoc.org). CPEP is a 501 (c)(3) organization offering comprehensive clinical competence assessments, customized education plans for physicians, and focused educational programs including Medical Record Keeping, Improving Interprofessional Communication, Prescribing Controlled Drugs, and ProBE (Problem-Based Professional Ethics).

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Forum Focus – Physician payment reform and the SGR fix

After 18 years and 17 “temporary” patches, Congress finally passed legislation – the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – earlier this spring to permanently repeal and replace the Medicare physician sustainable growth rate (SGR). The SGR fix and its implications for physician payment were the subject of a recent Physician Leadership Forum webinar.

The SGR formula was replaced with specified payment updates. For the next four years, Centers for Medicare & Medicaid Services (CMS) will apply an annual update of 0.5 percent to the physician fee schedule. Beginning in 2019, payment rates will remain flat, and physicians and providers paid under the physician fee schedule must choose whether to be paid under a merit-based incentive payment system (MIPS) or through alternative payment models (APMs).

The MIPS will tie physician payment directly to performance measurement. MACRA sunsets the current-law physician quality reporting system, meaningful use and value-based modifier programs and incorporates the measures and processes for these programs into the MIPS. Professionals’ performance will be assessed in four specific areas: quality, resource use, clinical practice improvement activities and meaningful use of electronic health records (EHRs). That performance will then be used to determine a payment adjustment. The payment adjustment – in the form of bonuses for high performer and penalties for poor performers – will be assessed on a sliding scale and capped at +/- 4 percent in 2019; +/- 5 percent in 2020; +/- 7 percent in 2021; and +/- 9 percent in 2022 and subsequent years.

As an alternative, physicians and other professionals who receive a significant proportion of their payments through an entity that participates in a qualifying APM, such as the Medicare Shared Savings Program, will earn an additional 5 percent payment each year from 2019 through 2024. In addition, beginning in 2019, qualifying APM participants are exempt from the MIPS, as well as most EHR meaningful use requirements. A qualifying APM entity must require use of a certified EHR, bear more than nominal risk for financial loss, and tie payments to APM participants based on quality measures comparable to those used in the MIPs.

Bryan Gamble, MD, MS, FACS, president and CEO of the Florida Hospital Medical Group, discussed the work his medical group has done to manage the clinical and financial risk in alternative payment models. He discussed the different categories of payment and how a larger percentage of Medicare fee-for-service payments will be linked to quality and APMs. He said his group is focusing on the way they deliver care, following the Triple Aim of improving the health of the population, improving the quality of care they receive all while reducing costs.

Gamble described other factors driving change and dollars in the marketplace such as value-based payments and a movement from inpatient to ambulatory space. He especially underscored the increasing role of consumerism in health care. He said patients are looking for convenience in handling their health care needs. They’re interested in technology and connectivity. In the near term, he said compensation will be determined on a number of issues such as coding accuracy/audits, as well as Stark Law implications, fair market value, commercial reasonableness, and designated health services.

For more on this issue, see our webinar SGR Fix: Implications for Physician Payment.