CDS as a physician extender?

sbeatty

My director has suggested that we need to think of innovative new ways to assist physicians to document with more specificity. I agree. We've discussed portable electronics such as Ipads so that a verbal query could immediately be answered by handing the device to the MD. Since we don't have our EMR implemented yet (go-live next June), she has asked if in the meantime we could be credentialled as physician extenders, and when we ask a verbal query and get an answer, we would document this in the record and the MD could co-sign. She is investigating CMS and HFAP regs, and our credentialling policy to see if this would be appropriate. This makes me nervous. It seems like we're setting ourselves up for a major compliance issue. I'm not suggesting that we would do anything wrong, but I also don't want to implement a process that would allow for such activity. Please let me know your thoughts. I need specific guidleines that support or rule out such an activity. Thanks much.

Unknown

Below are 2 AHIMA documents in regard to guidance and ethical standards which you may find helpful.

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047842.hcsp?dDocName=bok1_047842

http://www.beckersasc.com/asc-coding-billing-and-collections/ahima-brief-provides-guidance-for-clinical-documentation-improvement-programs.html


To become credentialed as physician extenders would be very unstable ground for a Clinical Documentation Specialist.

This would be my opinion: as a Clinical Documentation Specialist we should set a very high standard that in no way could be construed as documenting for the physician or putting words in the physicians mouth.


Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Menorah Medical Center

evanspx@sutterhealth.org

Seems like a direct conflict of interest and I would get an opinion from
your Compliance Dept.

Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739

dbutler

I agree with Charlene -- to me this has the risk of being perceived as questionable by external auditors, and we must be very cautious to ensure that any process of this sort is actively engaged. Somehow, design a process that the physician is consciously aware of the specific documentation and how that assistance is being provided, and be comfortable that their signature is an individual, conscious choice.

I think most folks are aware of what the reality MIGHT BE as far as the latittude that can develop in a broader sense (ie, clinical physciain extenders, not CDI function) with physician extenders (physicians relying on verbal discussions and perhaps not reading as closely the actual documentation before signing).

I also feel it worthwhile to point to a presentation by Holly Flynn from University of Washington Medical Center & Mel Tully from JA Thomas at the 2010 ACDIS conference (Care Documentation as a Clinical Process) where she did discuss how her facility functions with the RNDS. Slides 14 to 30 describe in detail their process (including screen shots). There is a lot of positive aspects to their approach.

Actually, it would be very interesting to hear an update.

Holly's presentation also has outstanding information about quality outcomes that have been strongly influenced by their RNDS role which was

I don't know of anyone else off hand with this type of process, though some of the facilities that have implemented JATA's Clinical Integration Specialist role might have some insight.

One more point -- there is also the ACDIS Ethics Statement that would be worth referencing along with the AHIMA Ethics that Charlene referenced.

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

sbeatty

Thanks, Charlene and Paul and Don. I've also gotten feedback from Glenn Krauss and Lynne Spyrzak. You have all verbalized my thoughts exactly. I don't want to seem like I'm not a team player here, but at some point physicians simply have to take responsibility for their actions-or lack thereof. My colleagues and I feel very strongly that this is NOT the path we should take.

catladyrn

Late to the party (darned time zone!), but...

I did know a CDS at another facility who would write verbal orders (e.g., Add acute systolic heart failure to diagnosis list, V.O. Dr. Smith), but that goes way outside my comfort zone. Totally agree with everyone who's said that what your facility wants you to do is a bad idea. The patient record should never reflect a vested interest on the part of the person documenting (one of the many reasons not to discuss reimbursement when querying a physician, and also why leading queries are not ok), and a CDS who is measured on asking queries and getting them answered has a vested interest in what's in the chart.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

Unknown

If you are a CDS with a license, you must abide by your state's scope of
practice. The facility can demand anything they want. However, if that
demand falls outside your scope they have no grounds. More importantly,
any outside auditor would reasonably ask what the credentials were of
the person designating a new diagnosis. If the credentials do not
include MD or NP or PA, your facility could be facing some serious fraud
charges. At best, they might be looking at reimbursing money big time.

So I think you are very wise to avoid that slippery slope.

Donna

Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com

sbeatty

Thanks to all for the excellent feedback. My director is very supportive of us and seems a bit surprised that we felt something unethical was being suggested. I'm not really sure what she had in mind when she suggested our credentialing as physician extenders. In our facility, a physician extender is not an NP or PA, and there is never any ability to make a diagnosis. They function more as scribes, or as medical assistants who get all the diagnostics together and previous records/consults that have bearing on the current stay and place them in the chart for the MD. The idea is to facilitate their work, not to do it!! The credentialing is for very specific activity that is spelled out in detail. We currently don't have our queries as part of the medical record. If we need to be facilitators, we need to revisit queries as part of the legal medical record. That makes more sense to me. I'm still unsure how she had intended us to help the physicians, but I really appreciate the support of all of you. Our program needs to keep it's focus on the quality of the medical record. At the end of the day, physicians simply must take responsibility for their practice, which includes documentation. I'm sorry that they've had years to develop bad habits without any recourse being taken. That was then, this is now.