Quality – the Documentation Challenge

Once upon a time, the healthcare industry was where the public turned when they were ill, injured or seeking preventative medicine and those services were rendered by caring medical professionals whose mission in life was to heal people and prevent/detect illnesses/injuries through appropriate interventions such as screenings and vaccines.

Improving Access to Care – Roosevelt & Beyond

Even children as young as 6th grade (in AZ) are familiar with the iconic photos that became the face of the Medicaid and farm relief endeavors of the Roosevelt administration. But assistance on that grand a scale has a cost and that cost has to

As the Rand Group reports,

Since at least the 1980s, the traditional fee-for-service model of health care payment has been challenged by reforms that alter payment methods in order to limit costs. Critics say that the persistent use of fee-for-service—where health providers are rewarded only when they provide more care—encourages unnecessary health care spending without enhancing quality or efficiency (2011) http://www.rand.org/news/press/2011/02/22/index1.html

Fast-forward to 2013 – the documentation, one-size-fits-all, government-regulation-addled healthcare industry has become the single most obvious case of failures in effective documentation engineering (technical writing) in the United States (my opinion not a researched fact). Members of the public are trifurcated into the strata of

    • Publicly Funded & Government Overseen Care (Medicaid/Medicare)
    • Privately Insured
    • Uninsured

Quality – the Documentation Challenge

CMS has endeavored to restore quality as the basis of healthcare in the United States, but rather than empowering providers to resume their healing & prevention mission; the quality endeavors have furthered the documentation doom of the industry.

17 Quality Measures are applied to the healthcare industry & are measured only in part through clinical outcomes and evidence based care. The best study that’s available on the impact of these measures can be downloaded for individual reading/use athttp://www.rand.org/pubs/technical_reports/TR841.html

The burden of measuring quality – in a way that meets the CMS standards so that Medicare reimbursement occurs at the corresponding quality-based rate – is on all Medicare providers. Each of them has to either devise a measurement tool or contract services from a quality surveying company that extracts the data.

And THAT is where documentation, accuracy AND audience analysis go “humpty dumpty” … engineering data collection models to reflect the “right” data compared to the “right” measures, funding the electronic health record mandate, cultivating survey questions so that they solicit accurate information from patients without bordering on inane is a challenge, delivering the survey in a cost effective manner by culturally competent individuals, reporting the data in a way that promotes accountable care models, scrutinizing the data to understand that sometimes the “beans” of data are actually pebbles that the patient was carrying at the time of care and needed to offload, the litany of challenges goes on and grows in complexity as the infrastructure for care delivery becomes more weighted down.


Further complicating the engineering of ‘measuring’ quality is determining which audience is being served. “Quality” as a term implies that we’re seeking to “serve” the patient by improving the delivery and standard of care. But to have the “quality” measures be manageable, the “audience” needs to be the facility & the provider. To have the “quality” measures positively impact reimbursement rates, the “audience” needs to be Medicare (as a general term, there are nuances that aren’t warranted here). Compound all that with the consideration that eventually our legislators are going to “do something” with this data (snarky air-quotes relating bureaucrats to doing something fully intended) – most likely decide that the care can be delivered faster, cheaper and with more administrative fees getting paid to the government entities whose job it is to provide payment.

AND Community Benefit is a Factor

AND if the provider whose quality is being documented happens to be not-for-profit (more than ½ of the facilities nationwide ~2900 +/- hospitals according to the American Hospital Association) the costs of those surveys AND the data from them becomes available to the public (at least in part) via the annual 990-H filing. So the data has to be rendered in a way that blots out any information that might identify the patient or his/her DRG (diagnostic related group) – but use the data to figure out what programs need to be constructed to meet community needs … programs that aren’t replicated in the community and with outcomes that are measureable and reportable.

The Best Analogy

For the past 2 semesters in addition to completing my academic and professional workloads, I studied for a professional certification exam (I work in healthcare finance) – an exam that I blessedly passed 4 days ago – and it occurred to me, as I was driving home that healthcare quality & community benefit are a lot like listening to the woes of a couple going through fertility treatments – regardless of the length of treatment and level of intervention – at some point the couple despairs “it’s starting to feel like a job” … taking what should be a simple normal aspect of human existence and turning it into a series of interventions, documentations, and quality analyses obfuscated & distanced by cold sterile clinical environs.

So …

The Pollyanna perspective is that the bureaucrats and legislators need to get back in touch with the people their programs are meant to serve.

Make them hold the hand of a cancer patient who lost her insurance in an ugly divorce and whose medications aren’t covered, so she is only eligible for palliative care. Make them be accountable for telling her children that the government doesn’t care enough to “count” their mom’s care as charity care because she’s too sick to do the financial assistance paperwork and “presumptive charity” hasn’t gained the stamp of approval yet.

Make them sit in the Head-Start/Early Intervention meetings with parents whose children need OT/PT and speech but can’t afford it – watch as they discover that the cost of what they “need” to provide for their children forces them to accept the publicly available one or two sessions a month and see the child’s progress stagnate because his/her parents can’t afford $5K/month in private party copays to access 3x/week services that would catapult the child past early intervention and into success.

Spend a late night in the ER with a young mother whose child is sick and watch as her joie de vivre is quashed by a reminder from an ER Doctor that the child’s immunizations aren’t up to date & that’s borderline neglect – and recognize that there may be extenuating circumstances such as the child’s insurance lapsing and the “affordable” care act’s impact making regular childhood immunizations to cost $300 every 3 months in the first year of life. And then listen in a week later when the surveying company calls and asks the young mother (in 10 minutes of her non-existent free time) about her experience – listen as she recounts that she went to the ER because her child was that sick & she didn’t know what to do or how to get his fever to come down and she was worried he might have a febrile seizure … and how her take-away from the experience wasn’t that she did the right thing (to bring him in for iv fluids and oxygen and antibiotics) but that she’s a bad mom because her baby’s shots are a few weeks over-due.

The realistic perspective is that the issues need to be taken TO the bureaucrats & legislators by people who: speak their language & play hard-ball at the same game of semantics and cost-containment initiatives; people who have seen the miracles of modern medicine save lives and change outcomes when providers and patients are able to be a team allowing intuition – not legislation – to lead the way; people whose give-a-damn is fueled by wanting to bring comfort, healing, and wellness to individual people, not by re-election and campaign contributions.

The discourse about healthcare in the US is broken – and the path to setting it right starts with changing the documentation challenges.