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.”
A year after making that change, the rate of documentation in the practice had increased to 82.33%, and by the second of quarter of 2017 it had reached 99.33%. “This is a concrete example of how by agreeing to agree and changing our culture we were able to achieve measurable improvement,” he said.
In other example involving the IRIS Registry, the practice’s performance for optic nerve evaluation in primary open-angle glaucoma was 45.97% when first calculated, compared with the registry average of 72.32%. The blame was pointed at the software- “it must be a glitch”-since the scribes and physicians were certain data were being correctly documented.
Motivated by their seeming “failure” at performing so far below average, the physicians began to investigate. They found that their EHR system did not recognize their documentation of an optic nerve evaluation, for purposes of the IRIS Registry, when the cup-to-disc ratio had not been entered following an exam performed with optical coherence tomography. Despite all the other data from the analysis, lack of that number meant no credit in the numerator.
Now that this omission has been corrected, the practice has a 78.64% score for optic nerve evaluation. When the performance data for a practice is not up to the expected standard, another way to investigate the problem is by examining the data for provider variation, Dr. Colloton said. If the data show that certain providers are performing well below average, it opens the door to conversations about how to deliver a higher level of care.
Changing EHR for the better
“We have been able to use the tools the IRIS Registry has given us to encourage our doctors to agree to agree, and that can be a tricky thing to accomplish,” Dr. Colloton said. “The IRIS Registry serves as a tool to help us clarify our communication with our doctors and improve on an already positive office culture while demonstrating measurable improvement in performance.”
Edward L. Colloton, MDP: 309/662-7700 E: firstname.lastname@example.org
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.