Getting members of a physician group to agree on the terminology used to document care is essential, and has an impact on communication within the practice as well as reimbursement.
Harmonizing documentation from your electronic health record (EHR) system can improve both intra-office communication and the documentation and reporting of quality metrics, according to Edward L. Colloton, MD, an ophthalmologist in private practice in Bloomington, IL.
Several years ago, the four-person practice embarked on an effort to get all the “alpha types” in the anterior segment specialty group to agree on terminology used in documentation and reporting and used the reporting from the American Academy of Ophthalmology’s IRIS Registry (Intelligent Research in Sight) to motivate physicians to be more consistent with their language. It is common for the clinicians in a group to have strong opinions on how to do things, Dr. Colloton said.
“Everybody knows that the way they do it is the right way to do it,” he said. “It’s very difficult to get those personality types to agree.” However, common sense dictates that agreements must be reached on some key issues, and that achieving a consensus is not a trivial issue.
Dr. Colloton recommends that practices acknowledge that while there is often more than one way to say the same thing, everyone must agree on an accepted usage. For example, a particular change on the optic nerve head could be called a circumpapillary change, peripapillary atrophy, a scleral crescent, a myopic crescent, or several other terms. To avoid confusion, particularly for technicians and transcriptionists, choose a term and stick with it.
Terminology can also make a difference in reporting and reimbursement. When his practice began participating in the IRIS Registry, Dr. Colloton discovered that for the second quarter their rate for documentation of presence or absence of macular edema and level of severity of retinopathy was 62.65%, which was below the benchmark registry average of 65% despite insistence from the doctors and scribes that they were documenting this data. A closer look showed that doctors weren’t getting credit in the numerator because mild background diabetic retinopathy wasn’t being accurately described.
“You and I might agree that a few micro aneurysms with extrafoveal exudate and rare dot hemorrhage is mild background diabetic retinopathy, but our software didn’t know that until we told the software that what we had just described is mild background diabetic retinopathy,” Dr. Colloton said. “We specifically had to add that language to the dropdown.”
Edward L. Colloton, MD
P: 309/662-7700 E: [email protected]
This article was adapted from Dr. Colloton’s presentation at the 2017 meeting of the American Academy of Ophthalmology. He did not report any financial disclosures. Cohesive, uniform terminology can also improve practice reimbursement percentages.