Are hospitals missing the woods for the trees? A classic example of clinical documentation

I recently got back from the HIMSS conference which happened in Las Vegas this year. During my visit I met several companies and startups and was really excited about the ideas, concepts and solutions that were presented at the conference. It was really exciting to see so many companies working on improving the way care is provided by physicians and received by the patients. The overarching themes found in the exhibit hall were analytics and population health. They seem to be the real hot buttons in the industry.

I also met several people who are working in the clinical documentation space in the healthcare industry and I had an opportunity to see some of the exciting things they’re working on. I had a very interesting conversation with a senior executive from a company who was sharing with the visitors to her booth about a large healthcare system that started using their integrated front-end speech recognition system as part of their enterprise EHR application. Being a member of the clinical documentation industry, I always received mixed feedback about speech recognition whenever I spoke to doctors, CEOs, hospital administrators, HIM professionals etc. While the technology companies are really gung-ho about how speech recognition technology is really enabling physicians to complete their care documentation faster and cheaper, I always wondered about the macro level implications of using this technology. Even from the provider side I have received mixed feedback. While some of the providers are really happy about having the ability to complete their documents themselves using front-end speech recognition, some of the providers find it very intrusive in their day to day routine. The latter seem to prefer traditional dictation over speech recognition because they seem to enjoy the peace of mind knowing that a trained and experienced professional on the other side is listening to their dictation and transcribing their notes. They also know that in many instances the documents get reviewed by QA staff to make sure that the documents are accurate and complete. This ability to dictate, these physicians feel, gives them the luxury to spend quality time with their patients and document all aspects of care that has been provided to the patient while the patient is in their office or in the hospital.

The industry is really excited about the adoption of front-end speech recognition technology as an integrated part of an EHR, and they continue to highlight how fast physicians are able to complete their clinical documentation and how physicians are becoming more productive and efficient in using this technology. However, I’m yet to come across a physician who told me how excited they are about doing clinical documentation themselves. They always feel that is a chore which they wish they didn’t have to do in the first place. It is much like how my teenage son feels about tidying up his room every week. He does it not because he loves it but only to avoid his mom’s nagging. I know more and more hospitals and their managements are pushing their doctors to use this technology, but does fast and hasty documentation compromise quality, integrity and completeness? I always wondered if there is any hospital out there that has really studied the overall impact of the utilization of speech recognition technology on the quality and integrity of clinical documentation.

With the adoption of ICD-10 coding and the transition of hospital reimbursement systems from volume to value, I think the ramifications of using such technology could be significant. In an environment where it has become extremely important to capture laterality and specificity that is required by ICD-10 coding, and in an environment where the severity of illness and risk of mortality measures have become critical not only for reimbursements but also for hospital’s quality rankings, I’m really unsure whether hospitals and physician offices, in the process of saving money on transcription, are losing out on these important metrics. These are important factors to be considered because more and more patients are looking at hospital and physician quality rankings, which are now regularly published on the Net before they choose a hospital or a provider. The healthcare providers are not only facing decreasing revenues but are also facing increasing competition.

When the burden of maintaining high quality clinical documentation is moved from back office and onto the lap of the physician, who is least trained in performing that task, quality and integrity will suffer. The emphasis on speed and productivity from the physicians by the hospital could result in the physician being brief in his or her documentation and in the process omit important details.

So if a hospital system with annual net patient revenues of $250 million and 15,000 discharges in a year, saves $250,000 per year on transcription costs that equals to 0.1% of revenues. But let us look at what the system could be losing by focusing on that 0.1%. Even if one in 50 charts (an extremely conservative estimate) an inaccurate DRG that does not reflect the severity of illness or risk of mortality of a patient who has received the required care, the loss in reimbursement could be at least $2500 (again a conservative estimate) per chart. For 300 charts that potential loss could be close to $750,000. This cost does not include any denials due to incorrect coding of charts. Poor documentation could also result in RAC audits which again are very expensive. Bear in mind that all these could result in lower quality rankings for the hospital which could result in potential loss of patients. When you add up all these other costs, the loss could be much larger than $750,000. So in the process of saving $250,000 the hospital could be losing more than double that amount. Is this a classic care of missing the woods for the trees?

I think it would make an interesting project for anyone interested to research and analyze the macro level impact of shifting the onus of clinical documentation from back office to the physician and from transcription to speech recognition. I think there is more to it that meets the eye.