Nursing Shortage Explained: Capture Those Resources!

The references to massive bloated bottom lines are every where with isurance, claims, denials, request of proof, preauthorizations, submitting and resubmitting.  It's a circus out there!  Only this circus isn't any fun.  And it's adding billions and billions of dollars  to your health care costs. Plus, it's getting worse with each passing year.

Remember when nurses went to school to be nurses?  When they took care of patients just like doctors?  The Medicare National Bank has changed all that.  CMS has destroyed health care delivery and created a massive bureaucratic mess.  With each new layer of rules and regulations they impose to fix something that they broke, they create all other messes.  These messes  add more to yours and my cost of receiving care.

I would like to welcome to my humble hospital the latest in a long line of bloated bureaucratic  cost structures courtesy of the Medicare National Bank.  With every change in the rules they make,  the hospitals must adjust, not only to maximize their profit, but to survive as well.
These are nurses who do hospital chart audits.   Like a super EMR  for auditing physician documentation.  They make sure that what physicians write adequately describes the clinical scenario necessary to get paid by the Medicare National Bank.   In other words, their job is to capture the resources used to treat the patient in order to get more money from government payers. 

Medicare rules  up  have now exacerbated the nursing shortage by creating a layer of administrative nurse documentation specialists taken away from direct patient contact to observe what doctors are writing and then collaborate with them to define more clearly what they meant to write in language necessary to capture resource utilization.  

Now, for hospitalists,  this is important, because if hospitalists can increase revenue generation for a hospital,  they become a more valuable  resource in the eyes of the administration who supports their existence.  But it also increases the cost of care.  Now you have a whole layer of salaried employees, each with their own retirement plans and health care benefits all Ffunded by the revenue that they will hopefully increase from helping doctors accurately document resource utilization. 

This is what I wish a progress note looked like for a 70 year old female with pneumonia on a ventilator:
Patient remains on ventilator D#3.  D#3 Zosyn. Hypotension resolved BP stable on levo.  Blood cultures remain negative.  Lungs remain course with no wheeze.  Rest of exam unchanged.  Continue supportive cares.  wean pressers.
In this scenario,  I have a chance to talk with a  family  for 10-20  minutes, talk with other physicians about our plans, thoughts, actions. I have time to do a lot of things.  Review plans with nurse,  talk to pharmacy.  Time is on my side. Instead this is what you get courtesy of the Medicare National Bank rules and regulations.


S)  ROS Unable  ETT in place
O)  95/45    110    100% on FiO245,  99.7     Drips Levophed
Reg pulse,  breath sounds course,  no wheezing.  interactive ETT securely in place.  + bowel tones, soft abdomen, 1+edema to legs, no rash.  central line site clean.

Labs  lytes fine.  WBC 18K,  Cr 1.6  Blood cultures -  pH  7.32 pCO2 47, pO2 110, PT INR of 4.8
CXR film reviewed shows stable infiltrates in left base
Tele tracings reviewed shows sinus tachy with paroxysmal Afib
Renal U/S c/w medical renal disease

I)  Community Acquired Pneumonia
2) Acute Respiratory Failure with hypercapnea and hypoxemia  Secondary to #1
3)CKD stage III, stable
4)  Diabetes, stable
5)Hx of venous embolism on coumadin, stable 
6) supratherapeutic INR
7) paroxysmal Afib stable
8)CAD not on ASA due to Hx of GI bleed, stable
9) Hx of GI bleed secondary to aspirin
10)  COPD on chronic home O2 
11)  Smoker
12)  DVT/PPI prophylaxis
13)  Hx of stroke

Plan.  Continue supportive cares.

Time in 0745   Time out 0820.

Same plan.  35 minutes of work.  No time with family or talking with other docs.  And the final decision remains the same.  Continue supportive cares. This is medical practice in 2008. And the more the hospital makes,  the greater my service is in the eyes of the hospital bank.  I become more valuable.  Do you think the patient or the family cares that I spent 30 minutes writing a note on the history of their grandmother?  They see me for 5 minutes and wonder why they get a bill for $200.  That's why.  In a nut shell.  And that's why we have a Nursing shortage.  To make sure I accurately capture the patient's resource utilization.  Any questions?  


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16 Outbursts:

  1. Happy Hospitalist: in general, I agree. Regarding the diagnosis/problem list, are you allowed to write something like:

    1. CAP- continue zosyn, pt improving.
    2-13. No change compared to 2/20/08 progress note.

    I seem to recall from residency that we were allowed to do this, though that was years ago.

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  2. The nice thing about certain electronic medical records is that they have logic built into it to capture this information, auto-fill the key fields, prompt you to use the best appropriate diagnosis, and as long as your computer skills are decent, it probably takes less time than writing/dictating a detailed note.

    You might think that CMS would be opposed to that sort of thing but insider word is they are very interested in that platform because in their eyes it is the most reliably compliant documentation system.

    Call me an optimist.

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  3. Sounds like your facility could use a visit from Cerner! They make some pretty kickass electronic charting solutions geared towards reducing the documentation labor of MDs and Nurses alike. From what I've seen of the health care system so far, it's DECADES behind current best-practices in information technology, hopefully when it catches up the labor involved in charting will decrease. I've gone from all-paper to computer-just-for-meds (developed in-house) to everything-on-the-computer (developed by a third-part) just during nursing school and it's amazing how more relaxed an environment it is when the documentation mostly "takes care of itself". A good example of this is ECG machines that automatically generate and transmit reports in PDF format, saving ED docs tons of time (from what I hear, I dont know too much about it)

    As for the nursing shortage..well, you might want to check out this fact sheet put together about the nursing shortage by the american association of colleges of nursing.

    http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm

    Documentation specialists aren't a new thing, I have a friend that used to perform that function at a state mental hospital decades ago. I'd hate for someone to get the impression that the existence of documentation specialists is a major contributor to the nursing shortage, here are the bullet points from that AACN fact-sheet:

    Enrollment in schools of nursing is not growing fast enough to meet the projected demand for nurses over the next ten years.

    A shortage of nursing school faculty is restricting nursing program enrollments.

    With fewer new nurses entering the profession, the average age of the RN is climbing.

    The total population of registered nurses is growing at a slow rate.

    Changing demographics signal a need for more nurses to care for our aging population.

    Job burnout and dissatisfaction are driving nurses to leave the profession.

    High nurse turnover and vacancy rates are affecting access to health care.

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  4. I can't believe this.

    The comments thus far seem to all be attempting to either help Happy Hospitalist in conforming to the twisted and foolish acceptance of a dysfunctional system, or to criticize his own choices in documentation.

    Folks, this is the tip of the friggin' iceberg.

    Documentation, in both inpatient and outpatient settings, seems to be more for the waste in the system than for the care providers.

    (Agreed, this is not the only factor...or even the most important factor...in the nursing shortage. Staffing ratios, mistreatment of nurses by other nurses and by physicians, and other factors leading to poor morale and burnout are all killing the nursing profession.)

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  5. the comment about a nursing shortage was tongue in cheek. It was not meant to be the main thrust of the post.

    The main point was that we now have fully staffed chart readers to guide physicians on what to write in the chart to maximize payment for the hospital.

    The fact that our hospital is using RN's was not the main point of this entry. It could be high school drop outs for all I care.

    The point is that in the current system, it has come to this at all is a pity and a shame.


    For the hospital, it's about maximizing dollars for time of rent.

    For the physician, it's about preventing lawsuits.

    And for the patient.

    Well, I don't think the patient really gives a crap what you write.

    They just want to get better for the least amount of money.

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  6. "A good example of this is ECG machines that automatically generate and transmit reports in PDF format, saving ED docs tons of time (from what I hear, I dont know too much about it)"

    I know you didn't mean it that way... but the above statement is totally hilarious.

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  7. You forgot how much that nice color-coded form added to the cost of documentation...

    Great example of the ridiculous lows that pay-for-perfomance measures have taken us...

    You da man, Happy!

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  8. EMRs and payers has a bit of an arms race feel to it. As we get better at documenting to their ridiculous requirements, they'll change the rules (i.e. "blended" outpatient 99213-99214 codes).

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  9. to the 3rd poster:

    Cerner Sucks

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  10. Paperwork is now MORE important than people.

    Kafka or Orwell, or Rand or somebody like that has already written about this sort of thing, but as fiction--it has become reality.

    So much for Western Civilization...was fun while it lasted. Killed off not by an invading army but an army of beaurocrats...

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  11. As someone in the business of educating hospitals on the long-ranging impacts of the whole "transparency" in healthcare movement, both upon the hospital as a whole as well on individual practitioners (or at least those that get reported in the discharge data as either attending and/or operating physician - if you don't get reported, you essentially don't exist from a report card standpoint), this post is near and dear to my heart.

    Personally, I am a strong proponent of provider-wide measures and transparency (ala the approach taken by Paul Levy of runningahospital fame). Physician scorecards? Not so much, yet, but there's a great demand out there to just talk about the realities of the data stream: from physician documentation to coding to the State/other oversight agency to the quality report card or website of the day.

    What I am most struck by when I talk about how this data is being used is the large percentage of physicians that are completely unaware of what happens to their documentation after they are long done with the case. Many are comepletely blindsided when I am able to hand them a sheet of paper showing all their cases from the last year(s), sorted by APR-DRG, or by hospital, or payer, or by myriad other ways, showing things such as volumes, average length of stay, mortality rate, charge/costs per case, # of secondary Dx codes reported, admit/discharge status, patient age and sex cohorts, etc. Yes, we show both observed and " expected" values on many metrics, using patients' APR-DRGs as the severity adjustment. Physician names and license numbers are prominently displayed on the top of the page. First question is typically "Where'd you get this?!" Answer: it is all publicly available from the State DOH (New York, in this example).

    Once they are over the shock that all this is out there for the taking, conversation usually goes to all that is wrong with severity adjustment, low sample sizes, these measures are crap, these aren't really my patients - I was just consulting, etc. Valid arguments, to varying degrees - but none of them change the bottom line that none of this is going away anytime soon, it's the reality of being a physician in a hospital now, like it or not.

    Anyway, I found your post most interesting given that you are a hospitalist. In my experience, in discussions with hospital leadership (medical or otherwise), nearly all state that one of the biggest benefits of having a hospitalist program is that the hospitalists are usually by far the best at patient documentation vs. other attendings. Many tell me they wish all their docs documented as well as their hospitalists.

    I feel for your plight, I really do. I agree 100% with your stance that time spent documenting, or being asked to re-document, is time away from your patients. But I also know your administrative pain isn't likely to go away anytime soon. EMRs and their ilk may help, we'll see.

    Others commented on clinical documentation specialists being the norm in their expereience, I would have to agree with that assessment as well in my experience - a hospital NOT employing one or more such specialists is the rarity. You've hit all the reasons in your post, and yeah, a lot of it is tied to reimbursement. But, slowly, I'm hearing more and more that focus is drifting over to putting the best face forward for report cards, and a lot of this push is coming directly from the Medical Directors and VPMAs.

    I'm sympathetic to the demands being placed on physicians, in part from reading your stories and those of others in the blogosphere, and in part because a good number of my friends are physicians - so when I am talking about public data and transparency and what it all can potentially mean to medical staff, I always feel a bit guilty - I wonder if there is way to discuss the topic with physicians in a manner which is MEANINGFUL to them in some way.

    So, if I may ask, what would you say would be ANY sort of benefit to YOU (short of long term) to full and accurate documentation? Maybe the answer is it just keeps the managers and bureaucrats off your back - that's a fair reply. But is there ANY foreseeable benefit to all this time and effort from your perspective? I am genuinely interested in your take, as it would help me better do what I do to have your input.

    Sorry for the length of the comment.

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  12. The clinical documentation specialists are a pain in my ass. Let's say I drain a perirectal abscess at bedside. Inevitably, I get called questioning whether I did "sharp" debridement or just debridement. "Could you please specify in the chart, Dr." No, I actually used a dull butter knife. Or, "we noticed the patients hemoglobin was 11 pre-op, and now it's 9.5; could you please write 'acute blood loss anemia' in the chart?".....even though the "drop" merely represents dilutional drift secondary to IV hydration.... happens every single day.

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  13. Very interesting perspective. I would say that the name of your blog is a misnomer since you don't sound like a "happy hospitalist"; you sound anything but. Perhaps the requirements placed on physician documentation are a pain in your backside, but nevertheless, they are the reality of practicing in medicine, whether in the hospital or the clinic. In other words, it's part of the job.

    In any other professional field (or non-professional, for that matter) processes and practices change, often overnight. You come in to work to learn that you no longer will do things the way you did yesterday: now it's a new way. It's my observation that physicians are the only group who can't accept this. They've been balking at EMRs for years; hospitals implement every other part of the electronic record, but the MD orders and physician progress notes are invariably the last piece to go live. Why? Because physicians don't want to be bothered to learn how to learn the electronic charting system even though numerous studies show that legible, accurate orders and documentation prevents adverse events and lowers mortality.

    A previous commenter referred to "physician profiling". It's here, and it's completely based on the ICD-9 codes assigned by the coder. Physician documentation, not anyone else's drives this process. So if you think that by omitting diagnostic terms and continuing to describe the patient's condition with vague terminology such as "low hemoglobin" or "looking better", your profile WILL suffer. Is the system fair? Perhaps not, but it is the reality of today.

    I would ask: why do you have a problem calling a spade a spade? A patient on a ventilator has respiratory failure, not respiratory insufficiency, or dyspnea. Coding language is not the same as clinical language. If you want your profile to reflect the type of patients you're treating, you'd better learn how to speak ICD-9 language.

    The people who pay you (hospitals, managed care providers, CMS) are basing your performance and risk (medical and financial) profile on the data entered by the HIM department. Your future ability to contract a fair reimbursement rate from these payers depends on the quality of documentation you've been providing. Do you think anyone looks at your written words when auditing your cases?

    So when you rant about the Documentation Specialists, you might want to think about this. Yes, they're helping the hospital's bottom line, but they're also helping YOURS!

    And to the other physicians who complained about receiving questions about their documentation: well, if you documented exactly what you did instead of expecting the coders to be mind-readers, you'd receive a lot less queries.

    A compliant, accurate record contains a diagnosis for each intervention and resource ordered. It should explain the "why" of each decision. If you've ever had to defend a case in malpractice court years after the fact, you'd soon realize the benefits of good documentation. The old adage "if you didn't document it, you didn't do it" is more true than ever.

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  14. Great article.

    Just FYI: it is coarse breath sound...not course breath sound.

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  15. I have spelling errors all over the place. I don't have time to fix them all. Thanks though.

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  16. Lynn, RN

    I couldn't have said it better. Soon, the physicians who can see beyond today will realize that their documentation is going to eventually effect their bottom line! Pay for performance is coming and if they don't start documenting appropriately it will affect their bottom line.

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