Mark Briesacher, MD: I'm Dr. Mark Briesacher, the chief physician executive at Intermountain Healthcare. Today, we have guest host Dr. Shannon Phillips, who's our chief patient experience officer, and she's talking with some of our caregivers about this very important topic.

Shannon Phillips, MD: Good afternoon. This is Dr. Shannon Phillips, I'm the Chief Patient Experience Officer at Intermountain, and I'm here with two of my colleagues who work in Intermountain's Physician Advisory Services. Want to introduce yourself?

Christine Foster, MD: Sure. This Dr. Christine Foster, System Physician Advisor. My background is internal medicine, and I have practiced for 17 years as a hospitalist. I became involved with Physician Advisory Services about five or six years ago and have really enjoyed that role.

Shannon Phillips, MD: Great.

Kearstin Jorgenson: Kearstin Jorgenson, I'm the Physician Advisory Services Director here for the system. I actually have worked at Intermountain since 2000 and worked primarily in revenue cycle and had a lot of opportunity to interface with the physician advisor services group, then had an opportunity to work in quality, which really I think aligns with the work that's being done in OPE. It's been fantastic to see where that's gone since I've been here.

Shannon Phillips, MD: Great. Someone might naturally ask me why would Physician Advisor Services and that work around documentation integrity and improvement be in the Office of Patient Experience? Chris, how would you answer that question? How does it fit?

Christine Foster, MD: Primarily, documentation is, in our training as clinicians, one of those things that you're taught write down this, say this, and say it in this order. As the industry has evolved, so have the requirements for documentation, and what we see more and more is how that impacts the patient individually, but also healthcare as a whole. I would say we have five fundamentals of extraordinary care: safety, quality, patient experience, access, and stewardship. I will tell you that if there is one core competency that we have that will impact all of those, appropriate documentation is one of those.

Shannon Phillips, MD: Interesting. Do you think the average provider gets up every day and says what I write down, that's it? Fill that out a little bit. Why is it so important?

Christine Foster, MD: Definitely not.

Shannon Phillips, MD: I bet they don't. Right? But, maybe they should, so make the case. Why are patients safer, for example?

Christine Foster, MD: Using an example is how many times have we come to the table to provide care for a patient and maybe not had the information we needed at hand. If I am seeing a patient, do I have an accurate med reconciliation list? Do I have an accurate problem list which is there to really represent that snapshot of the patient at that point and time? Is there a way that things surface to me that are meaningful? This care needs to be provided, and that has not traditionally been the case. In fact, a lot of times, I think you are tracking back mistakes in the medical record, or errors thereof, or you are discussing a patient's past medical history with them and suddenly they say I don't have that, I don't take that medication, that's not what happened.

Right there is part of the patient experience. There is trust. Do I trust the accuracy of the health record? In reality, the health record belongs to the patient and should accurately reflect the complexity and totality of his or her health. The story we tell about patients tells others about us, and if we get that right, everything else tends to fall into place.

Kearstin Jorgenson: It's interesting because I think as you talk about this story and how it tells about us, I've learned a lot just being in the quality department about how information that is coded then goes out to the public. I had an experience where I had a family member get on and look at some publicly reported data and didn't necessarily understand where that information came from. That really impacted their perception of a particular facility, and it’s been neat being part of this clinical documentation world, because we have been able to go in and actually review cases and identify errors that are going out to the public when they're making decisions on where they can get healthcare. It's been fantastic to see that we can have an influence on [00:05:00] that, because we really want to show and be representative of the care that's being provided by having accurate documentation.

Shannon Phillips, MD: I think quality and safety, because of the measurement publicly of that and using claims data, we have more than one thing to work on to get better. We have to have complete and accurate documentation so that it supports being able to care for the patient and accurately represents what's wrong and then we need to dig in and make the care better. I'd say when I got into this space, I thought I was getting into make care better and I realized it was an and. I think for some providers that can be frustrating, and if we take that high road, Chris, that you were talking about that it's the patient's record and it needs to be accurate, we owe that to our patients. I think the documentation plays so many roles, so really linked.

Christine Foster, MD: Yeah. I would add to that that there are things that we hit up against day to day. As a hospitalist for instance, I may have a case manager call me about a patient's status, should this be inpatient or observation? The first response can tend to be I just want to take care of the patient and at the end of the day when we get that documentation right, we are taking care of the patient. We've had patients who have had higher bills and their care denied outright by an insurer simply because documentation didn't support the need for that procedure. It didn't support a couple of extra days in the stay. It goes into that patient experience and also being a stewardship.

When we are a stewardship for accurately reflecting the complexity of care and the medical necessity required, we're actually providing access and protecting the resources we have to care for that patient.

Kearstin Jorgenson: Yeah. I actually think I've come to understand that the last experience that the patient has with us is their bill and we have had an opportunity to work on the denial side of things and the appeal side of things to really make that backend process and that experience that the patient has with their billing more positive because it's accurate and they don't have to spend a lot of time on phone calls. That's definitely [00:07:30] been another rewarding piece of this work.

Shannon Phillips, MD: I think you just touched on experience. Yay. Thank you. Another fundamental. If you weren't you knowing everything about documentation and that world, if you have a message for a frontline clinician, a primary care doc, a hospitalist, they've got so much to juggle. What's next and coming down the pipe? In documentation specifically and the integrity of that, where do you want providers to focus?

Christine Foster, MD: Well, I think from a behind the scenes perspective, there's a lot an organization can do to support those requirements so that things are surfacing at a level that is helpful to a provider at that point of care if we think about closing gaps in care. The message has gotten very complicated in recent years where you're hearing a lot of three letter acronyms thrown out, CMI, HCC, and that doesn't mean a lot to a provider. I think what is most important I found in my own workflow and in those colleagues of mine who have adopted some of these practices is use what is in your workflow. If you think about how we were taught to write a history and physical or how we were taught to write a soap note. I would say now that we are living in an electronic world, what are the tools that surface to us that are within our workflow?

The top three, I would call them vital behaviors, that have helped me in efficiency is to say, here's the problem list, have I reconciled it? Do I know that I trust the problem list, if I am treating one of those problems, continuing a medication, I pull that problem into my list and talk about it? Then on backside of that, if I happen to get a query in the inpatient or ambulatory care setting, I respond to that query. Those are the three vital behaviors that keep it simple for me. I don't mean that I have to know everything that's out there, but I have that snapshot.

Shannon Phillips, MD: All right. I'm going to see if I can past the test. Use your problem list to make sure it's accurate, delete what shouldn't be there, add when it needs to be, pull the problems into your note, and work them as is appropriate for the care that you're giving and if someone has a question of you of the documentation integrity or improvement opportunity, respond. Maybe your answer is, it's good the way it is, maybe they've given you something to consider, but respond. Is that fair?

Christine Foster, MD: It is. I think, over time, that also goes toward our caregiver experience. It's peer to peer hand off. If I have done a good job in my most recent note, you picking up a patient for me has a more clear image of what went on with that patient's most recent care. It's how we take care of one another additionally, I think.

Shannon Phillips, MD: There you go. Be a good steward of the chart and the documentation so that the next person comes in more informed, can give safer care, and can thread the next piece of documentation into that same quilt. How's that for a really silly and wonderful analogy? I think, Kearstin, you mentioned that in other roles that you've had here that you've had opportunity in reviewing care that where you've seen documentation maybe could've made a difference, I may be putting words in your mouth, but you want to share what you shared a little earlier?

Kearstin Jorgenson: Yeah. Definitely. I had an opportunity to work early on in the zero harm journey in going through and reviewing serious safety events. In that process, we reviewed a significant number of those serious safety events going back a couple years and really across the gamete. It actually was very heartbreaking experience and a very emotional experience, probably the most that I've had in working in healthcare and so it was very poignant for me to think about that. But, what I really took from that experience was a trend that I had identified and that was in care transitions like you just spoke to, there was an opportunity for individuals on the care team more specifically to make sure that pieces of the record were documented really to situate the next group to be more successful.

I left that feeling a resolve to be a better contributor to those that we have stewardship for and trying to make a difference and making sure that some of the mistakes that we have made in the past are not replicated and that's really what drives my passion for this work is being able to see so many heartbreaking experiences and knowing that we can make a difference and sometimes it's those little things that can make the biggest difference. The little things and just taking time to document what has happened with that patient weighed a significant error that impacts people for their life.

Shannon Phillips, MD: Yes. Yes. Right. What else should a provider know about these sorts of advisory services? What else is going on behind that scenes that we probably should maybe thank people for even though we maybe don't even know what's going on or I might be exaggerating? I don't know. What else happens that supports our clinical care, supports the quality of care obviously in revenue as a piece as well? What might a provider not realize is in this work?

Christine Foster, MD: I think the day to day challenges is what come to mind, which are the behind the scenes processes that ultimately do surface to a provider that seem to be a frustration. An example of that would be I'm called and that maybe the status of my patient seems inappropriate. And that is behind the scenes work for our conditions of participation with CMS. That way, we are constantly looking at documentation to reflect if this stay is medically necessary if you're in the hospital. In the outpatient setting, I would say we are moving into a higher at risk population for our patients. The way that we provide those resources, they didn't just come to us and say here is $5,000 for the life of this patient for this year and it's equal across the spectrum, they said we are going to pay you based on how complex this patient is to take care of.

How many conditions go into that? What we are doing behind the scenes often is vetting that the patient actually has certain conditions. Because you can imagine someone having 15 conditions is going to need more care, rightly so, than someone that may have one or two and so making sure that behind the scenes that those conditions are well documented adds to protecting the resources.

Shannon Phillips, MD: That's stewardship. That's an important topic that I think should resonate with doctors. While we are really good at saying the bill, your point being made I think is really important. If you get $5,000 for somebody with a single condition to take care of them for a year and then somebody has five other medical conditions and they would be paid $20,000 a year to take care of them, it's not just about we want to make more money, we have to take care of that patient. We're going to spend the money to care for that patient whether we get $5,000 or $20,000, and if there is patient after patient after patient where we're not being reimbursed what we need to actually provide the care, we're just digging a hole.

Christine Foster, MD: I think the resources in the community. If diabetes, for instance, is the number one chronic condition that we treat, if we're able to pool those resources to provide better care for a greater benefit, you'll see the benefit extend itself longer. It is about the cost of individual care, but it's also about the cost of care for a community [00:16:30] and that we are preserving those resources across the community and when we document appropriately.

Shannon Phillips, MD: Awesome. Reflecting on what matters most. I think I heard the patient's record is their own. We owe it to them for their safety, for the best quality care, and a great experience that it be accurate and complete and reflect who they are and that providers have the opportunity to be stewards of that record, stewards of resources by contributing and making sure the complexity is there and net/net, it's good for everybody. Right? Did I miss anything?

Christine Foster, MD: No. Simplicity. We've made it harder than it needs to be, so keeping it simple.

Shannon Phillips, MD: Keep it simple.

Christine Foster, MD: Yes.

Shannon Phillips, MD: I love that.

Kearstin Jorgenson: I think we actually have a good understanding that providers these days are asked to do so many different things, and we have an overall strategy within our group that we have set up different initiatives that try to make this more simple for providers: having resources that are looking at things ahead of patients coming in and leveraging tools and technology to make sure that the coding is appropriate. We're really thinking about the patients, but we're also thinking about the providers and how we can help them be successful in their workflow.

Shannon Phillips, MD: I think anything that tees providers up to be successful and ready and present for a visit is a win. I think that's a really important add and I think the work that's being done in physician advisor services is all over that. How do we get the patient and our providers ready, have a great interaction, and then close out with accurate and complete documentation. Thanks, you guys. Appreciate the time.