Documentation’s Effect on Readmission Rates

By Dava Stewart for For the Record

An HIM professional’s research led to interesting findings and more questions.

For Lee Wise, MS, RHIA, CHCO, identifying data patterns holds a special spot in her heart. “It isn’t just with numbers and facts, but with all facets of my life—right down to my children,” she says. “Do things line up? Does it line up with the anticipated trajectory?”

At AHIMA19: Health Data and Information Conference in Chicago, Wise and Nicole Miller, MS, RHIA, presented a session that spotlighted the former’s natural curiosity in numbers. “Transitions of Care and Timely Physician Documentation: A Research Project” examined the results of research Wise had conducted after taking on two usually separate roles and encountering something that just didn’t seem quite right.

Wise’s ability to spot patterns comes in handy for her work at Virginia’s Clinch Valley Medical Center, where she holds the dual roles of director of HIM and privacy officer. She began conducting the research that would be the fulcrum of her AHIMA presentation when she noticed an odd pattern emerging at the front desk.

“I’m looking at the readmission information. I’m seeing patients come in. I’m seeing it in case management and then in informatics. There was something there and I couldn’t quite put my finger on it, so I started spreadsheeting it. I started correlating the 30-day readmission rate with the daily admissions,” Wise says.

After examining the list of patients who’d been admitted in the last 30 days, she compared it with the daily admissions. Soon, she detected a pattern. “Now I can see who’s been in 10 times this year; 15 times. I had one person who had come back six times in eight weeks,” Wise says.

She started analyzing the discharge summaries of those patients who were being admitted most frequently. Her digging led to an interesting discovery. “Some of the people who were coming in most frequently were the ones who don’t have discharge summaries on record at the time of readmission,” Wise says.

Discharge Documentation Rules

According to the Centers for Medicare & Medicaid Services (CMS), all documentation, including discharge summaries, must be completed by physicians no more than 30 days following discharge. The discharge summary is critically important for patients who need further care following a hospital stay. For example, a patient may need to see a specialist after he or she is released or transferred to a long term care or rehabilitation facility. The providers at those organizations need to be aware of the care the patient received while in the hospital—and they often need this information well before the 30-day requirement.

Similarly, when patients are discharged to their homes, their primary care physician faces a knowledge gap when documentation regarding their inpatient acute care stay isn’t completed in a timely fashion.

Another CMS rule stipulates that if a patient is readmitted to the hospital less than 30 days after discharge, the hospital where the initial care took place is penalized.

Wise, who believes these two CMS rules are contradictory to some degree, suspects that at least some readmissions could be avoided with more thorough documentation being completed in a shorter timeframe.

A Multifaceted, Wide-Ranging Problem

The issue of timely discharge documentation and whether it impacts hospital readmissions is multifaceted. No matter the health care setting, it’s a concern that affects many different departments and staff. It’s important to facilities seeking to provide efficient, high-quality patient care; to professionals providing ambulatory, specialty, long term, or home health care; and, most importantly, to patients. A smooth transition of care means better patient outcomes, the goal of all health care.

Many physicians do complete discharge documentation in far less than 30 days, but the quality of that documentation is important as well. Sometimes the discharge documentation isn’t fully thought out. For some physicians, each patient encounter is transactional. “They don’t think about holding the hand of the next care provider,” Wise says.

Velvet Thorne, manager of care coordination at HealthEC, a population health technology company, has firsthand experience with the problems that can occur when there are gaps in discharge documentation. Because she works with patients in their homes, the transition of care from a hospital or a facility is a little different, with social determinants of health coming into play in a much more significant manner.

Patients and their caregivers need access to medication, they may need transportation to follow-up appointments, and they may have difficulty handling small tasks such as getting up and down stairs. All of those factors should be addressed in the patient’s discharge documentation.

Thorne says the initial assessment is as important to a smooth transition of care as the discharge paperwork, adding that the two steps are inextricably intertwined. “When a patient comes into the hospital and is admitted, there should be a discharge plan from day one,” she says.

Wise’s copresenter, Nicole Miller, a consultant who works mostly with ambulatory care facilities, views discharge documentation from a different perspective, noting that documentation snafus occur from the other direction, too. The physicians she works with may see a “patient come in for an annual physical or a well child visit, or for one particular problem, like a respiratory infection, and they do the documentation for that one issue. They may not think about how that note isn’t as up to snuff as it should be if the patient doesn’t get better and has to be admitted to the hospital for pneumonia.”

Those in the specialty care niche have yet another perspective on transition of care documentation. For example, take the case of a patient with a cardiology problem who is admitted to the hospital for a gastrointestinal issue. Two weeks after discharge, the patient visits the cardiologist. At that point, there’s a good chance the cardiologist will need to be aware of any care given while the patient was hospitalized.

“If someone looks at [a patient’s] documentation, they should be able to tell that patient’s entire story,” Miller says. “They should be able to tell what that patient has had and what they will need in the future. Even an outsider should be able to tell.”

The chain of events that make up transition of care has many links, and anyone of them could break and cause a problem, says James Dunnick, MD, FACC, CHCQM, CPC, CMDP, a boarded cardiologist with certifications in quality and utilization, medical documentation, and coding. He says that in a perfect world, physicians would complete all discharge documentation at the time the patient is discharged, while everything is fresh in their memory, but, “if you’re the hospitalist, and you get called away because of an emergent situation, you might not be able to do that.”

EHR issues, clerical errors in the electronic prescription process, and delays in transcribing physician dictation from the discharge may create gaps in the documentation, Dunnick says, adding that there are many places where mistakes can result in poor, delayed, or incorrect chart notes.

Too Many Solutions?

The potential solutions to care transition documentation gaps are nearly as plentiful as the facets of the issue. To some degree, how a person thinks the problem should be corrected depends in part on how the problem affects their work. For example, Wise suggests that requiring discharge documentation to be completed in a shorter timeframe could help.

From her perspective, CMS regulations provide physicians leeway but, in some cases, facilities are punished when a physician does just that. If a physician completes discharge documentation 28 days post discharge, it is deemed to be compliant. Yet, if the patient is readmitted in 20 days, the facility faces a financial penalty even if that readmission could have been prevented by complete documentation.

Also, patient satisfaction scores may be lower when there are gaps in postdischarge documentation. As a result, the facility’s reputation may suffer. After being discharged, patients are given a survey asking for their opinion of the care they received during their stay. If the patient has any issues with postacute stay care, it is reflected in their responses. Patient satisfaction scores, which are averaged using the survey responses, are posted on websites such as www.leapfroggroup.org for patients to peruse before they seek care.

As for Wise’s recommendation that facilities adopt stricter guidelines than CMS, she notes that some facilities require documentation to be completed within 21 days or the physician faces a fine. “I’ve seen facilities that charge basically a library late fee. It’s like 25 cents a day. It’s small, but it motivates,” Wise says.

However, Miller points out a potential drawback to such a strategy, namely that requiring physicians to work more quickly will only add to their already full plates. “We are asking them to do a lot,” she says. “What can we do to help?”

Dunnick agrees, noting that each new innovation in health care seems to be double edged. For example, he says that the trend toward having hospitalists on staff has many benefits for patients, administration, and physicians. Yet, at the same time, it means the doctor who sees a patient in the hospital is not the one who provides care later. “The discharge summary becomes the communication vehicle from inpatient care to outpatient care. Now the timing takes on an importance it did not have prior,” Dunnick says.

“Some doctors have challenges” when it comes to documentation, Thorne says. “It’s not always a team like it used to be.” To help with the task, she suggests that reminders and alerts be built into the EHR. “The doctors need to have some kind of support,” Thorne says.

In some ways, the many different perspectives and possible solutions make arriving at the most appropriate solution more difficult. Miller compares the situation to the industry’s ongoing quest to achieve EHR interoperability.

“It seems like so many times in health care we are putting the cart before the horse,” she says. “Like when EHRs were rolled out, and organizations were required to use them, but no one made sure the EHRs worked properly. Everyone needs to work together better. I think it’s difficult because it’s almost as if there are too many cooks in the kitchen.”

More Questions Than Answers — for Now

An interesting fact about Wise’s research is that it couldn’t have taken place until quite recently. Without digitization, the information that connects discharge documentation gaps and 30-day readmission rates was buried in charts. It’s possible that this problem existed even when clinicians had more support in completing tasks such as chart notes.

Wise’s research raises several interesting questions. For example, do hospitals that require physicians to complete their discharge documentation faster than 30 days have lower readmission rates? Do facilities that penalize physicians for not meeting stricter documentation deadlines have lower readmission rates? Would improved interoperability make transition of care smoother?

Wise says her early research considers only patients who were admitted and received a bed. “But what about people who come in through the emergency department?” she says.

Wise continues to study the issue, but admits that it could go on forever. Although she began simply by looking to see whether there was a pattern among the patients being readmitted within 30 days, it led her to consider how social determinants of health factor into the equation. For example, if patients don’t have access to the medications they need when they leave the hospital, chances are high they’ll be readmitted.

All of the unanswered questions combined with the massive amount of data that is now available thanks to EHRs will undoubtedly lead to more novel research. At the same time, health care will continue to evolve and change as value-based care becomes more predominant, technology continues to improve, and the roles of those in the industry take on new structures.

Anyone who works in health care, regardless of capacity, understands that this is a time of tumultuous change. Technology is disrupting almost every part of the entire industry, and at the same time roles are changing rapidly. Old silos are breaking down; this may ultimately be the solution to the documentation dilemma. After all, it was the fact that she was filling two traditionally unrelated roles that allowed Wise to identify the gap in discharge documentation that spurred her research.

“The EHR is giving us a better view,” Miller says. “We have a much better view of the information. [Wise] could continue going deeper and deeper into this, and where does it finally stop?”

Wise has the answer: “When I see something, I delve in deeper.”