New mobile app helps providers better document conditions and care

December 18, 2012
Retain thimerosal in global vaccine supply, say public health experts

One of the key features of health care reform is the linking of outcomes with reimbursement, a development that places even greater urgency on the thoroughness and accuracy of documenting a patient's condition and care. A new suite of tools – include a mobile app for iPhones and iPads – developed by the University of Rochester Medical Center (URMC) helps health care providers paint a more precise picture of the health condition of patients they treat. 

"The Centers for Medicare and Medicaid Services (CMS) has adopted significant coding revisions for reimbursement," said Yousaf Ali, M.D., the chief documentation officer at URMC's Strong Memorial Hospital. "They marked a substantial step forward, paying close attention to other serious conditions that sometimes piggyback on a particular diagnosis, better capturing just how sick patients are by creating more specific diagnosis-related groups."

Meticulous documentation of complications present at the time of admission, co-morbidities, and the rationale behind care decisions are not only linked to reimbursement payments for hospitals, but to quality of care and performance on public report cards as well. Individual providers' quality of care score cards are also linked to their documentation.

For instance, a provider may decide that, for good medical reason, a given heart attack patient shouldn't receive the standard aspirin upon discharge.   This is just one example of a routine "core measure" that CMS tracks to gauge how well hospitals adhere to best-quality practices. If the provider failed to note their logic in the patient's record, the missing aspirin appears to be a sloppy oversight – not a calculated choice.

Faced with this changing landscape, URMC leadership tasked Ali to work with physicians, mid-levels, and residents to better document care in a way that would translate into more thorough, appropriate coding.   The result was Documentation Improvement Tips for Physicians and Medical Providers, a resource that provides quick, practical documentation advice.

URMC conducted a pilot test of with Nurse Practitioners in a Med-Surg patient care unit to evaluate how documentation practices would change – after instruction and using the tips that Ali developed – over the course of a month. After 30 days, the average risk of severity of patients cared for by NPs was coded 2.90 – a .2 increase over the prior month's 2.71. For an institution like Strong Memorial Hospital, every tenth of a point corresponds to almost $1 million in reimbursement.

"This was a small study but it confirmed our suspicions that we were failing to fully document in a way that details the true acuity of the cases we take on," said Ali. "In order to stay competitive, earn back payments that are rightly deserved, and safeguard quality reputation, hospitals absolutely have to get better at this."

The Documentation Improvement Tips are available in several different formats. A new mobile app – called "URMC MDtips" – is available free of charge from iTunes .   An Android version will be available soon. The tips are also available to license from URMC in the form of a pocket reference booklet and a software package for hospitals that enable the institution to periodically send tips to providers. URMC has found that this approach makes documentation a priority and keeps it "top of mind" with providers.   Impressed by its breadth and utility, the American College of Cardiology, New York State Chapter has also licensed these tips from the Medical Center.

Explore further: Doctors who dictate their notes have worse quality of care than those who use other documentation methods: study

Related Stories

Doctors who dictate their notes have worse quality of care than those who use other documentation methods: study

May 21, 2012
Could the quality of care you receive be affected by how your doctor takes notes? According to a new study by researchers at Brigham and Women's Hospital (BWH), doctors who dictated their patient notes appeared to have worse ...

Study questions validity of quality measure for stroke care

August 27, 2012
One of the key indicators of the quality of care provided by hospitals to acute stroke victims is the percentage of patients who die within a 30-day period. A new study shows that the decisions made by patients and their ...

Primary care physicians play vital role in caring for diabetes patients

December 11, 2012
Previous research has shown that patients without a consistent primary care physician (PCP) have worse outcomes than those who do, but little is known about why this is true. New research from Brigham and Women's Hospital ...

Report suggests ways to improve health-care provider 'report cards'

March 5, 2012
As health care reform expands the use of "report cards" to grade health care providers, greater attention to reporting methods may be needed to assure the quality of such efforts, according to a new RAND Corporation study.

Recommended for you

Aging Americans enjoy longer life, better health when avoiding three risky behaviors

July 20, 2017
We've heard it before from our doctors and other health experts: Keep your weight down, don't smoke and cut back on the alcohol if you want to live longer.

Opioids and obesity, not 'despair deaths,' raising mortality rates for white Americans

July 20, 2017
Drug-related deaths among middle-aged white men increased more than 25-fold between 1980 and 2014, with the bulk of that spike occurring since the mid-1990s when addictive prescription opioids became broadly available, according ...

Parents have critical role in preventing teen drinking

July 20, 2017
Fewer teenagers are drinking alcohol but more needs to be done to curb the drinking habits of Australian school students, based on the findings of the latest study by Adelaide researchers.

Fresh fish oil lowers diabetes risk in rat offspring

July 19, 2017
Fresh fish oil given to overweight pregnant rats prevented their offspring from developing a major diabetes risk factor, Auckland researchers have found.

High-dose vitamin D doesn't appear to reduce the winter sniffles for children

July 18, 2017
Giving children high doses of vitamin D doesn't appear to reduce the winter sniffles, a new study has found.

Scientists develop new supplement that can repair, rejuvenate muscles in older adults

July 18, 2017
Whey protein supplements aren't just for gym buffs according to new research from McMaster university. When taken on a regular basis, a combination of these and other ingredients in a ready-to-drink formula have been found ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.