Why it’s Not About the Documentation

Direct verbal communication between referring and consulting physicians is the best practice.

Communicating in the chart, while convenient and useful, rarely provides the most accurate and complete information. The same is true for internal physician advisors – the internal physician advisor is essentially a consultant to the medical staff, providing guidance regarding appropriate resource utilization, billing requirements, and regulatory compliance – and as with any consultant physician, the best outcomes depend on physician-to-physician communication. 

The role of an internal physician advisor is broad, encompassing a variety of responsibilities in health systems across the country, but most internal physician advisors are responsible for performing secondary reviews related to patient billing status. When completing these reviews, the internal physician advisor should start with physician-to-physician communication, not an in-depth review of the documentation. This communication should occur in person, preferably on patient care units while attending physicians are admitting patients and making rounds. Of course, the chart (typically an electronic health record) needs to be reviewed, and ultimately, the documentation needs to accurately and completely reflect the attending physician’s thought process – but that alone is not adequate.   

The primary benefit of an internal physician advisor program is not high-quality documentation, it is the availability of physician consultants that are known to the medical staff. As credentialed members of the medical staff, internal physician advisors are intimately aware of patient flow in and out of the hospital, the typical barriers that affect efficiency, and the standard of care in the community. As such, internal physician advisors can have meaningful conversations with their peers and ask appropriate, probing questions. Why is the patient being admitted to the hospital as an inpatient? Is the hospitalization medically necessary? If so, is it reasonable to believe that the patient’s medically necessary care will span two midnights? Was that the plan all along, or is that now the plan after an initial midnight of evaluation and treatment? If the patient does not have medical necessity for hospitalization, is the admitting physician simply concerned that the patient does not have a safe discharge plan?  

It is the ongoing, daily, face-to-face communication that occurs between internal physician advisors and the medical staff that builds mutual trust and respect, and allows physician advisors to ask these probing questions without coming across as accusatory.

For those of us in the physician advisor world, these medical necessity questions may seem simplistic. But for practicing physicians with decades of ingrained medical training focused on other priorities, the ins and outs of patient status determination are rarely obvious. And in those cases, physician-to-physician communication not only teases out the correct answer, but also provides much-needed elbow-to-elbow education that allows the attending physicians to make the best status determinations in the future. 

Only after appropriate physician-to-physician communication has occurred should the entirety of the attending physician’s documentation be reviewed and addressed. Is it accurate and complete? Are there improvements that can be made? Is there conflicting information that needs to be clarified? When it comes to physician advisor documentation, it should be extremely brief, communicating the status determination without lengthy explanation or complexity.

If your hospital’s internal physician advisor is spending their day sitting behind a computer screen, you are missing a key component to the role – one that will make the difference between success and failure.

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Kathy Seward, MD, CHCQM-PHYADV

Kathy Seward, MD, CHCQM-PHYADV is a medical director of coordination of care at a nine-hospital system in southeastern North Carolina. She is also the co-founder of HPIR, LLC, a healthcare consulting company, and the developer of the innovative HPIRounds™ Solution, the best way to manage length of stay. Seward is a member of the RACmonitor editorial board.

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