Documentation, The BIGGER Picture
Doctors ask me all the time why I chose the worst subject in the history of subjects to teach – documentation. Originally, it was simply because many of us were getting absolutely hammered by insurance companies (commercial and auto) and our reimbursement was getting hit hard, or we were asked to PAY BACK money that had been paid to us (think Medicare and PI post-payment audits). Back then, I spent a lot of time, energy and money to figure out what the hell these insurers were talking about how we can finally beat them at their own game. But, then, something happened. I started to get requests from these same insurers to review chiropractic records. The first few I saw, I thought, “Wow. These are pretty bad. Good thing this is just a small sample size.” After reviewing a few hundred more, I thought… Ruh Roh. I mean, let’s face it. None of us really like to or even WANT to document. We know we have to (sort of…most of us), but we don’t want to do it. Trust me – I get it. But in my 33 years as a chiropractor and growing up with a father who was a chiropractor (60 years – can you believe that?), I’ve thought and heard from other chiropractors how no one takes us seriously, how we can never seem to get ahead legally and how that old friend “cultural authority” has seemed to elude us for all these years. But it wasn’t until I started looking at chiropractic records – and I mean, a LOT of them – that I realized that much of it is… Our Fault. Now, don’t get me wrong. I really believe that what we do as chiropractors is still as mind-blowing now as it was when I started practicing all those years ago. I really believe that the VAST majority of chiropractors mean well and just want to do their best for their patients. But the way we communicate what we do – what the rest of the world SEES from us – in our documentation – is not just bad – it’s downright AWFUL. And don’t think I’m giving you crap because you might be using a travel card and haven’t spent thousands of dollars on some computerized software (most of which suck, by the way) – I’m not. I’m giving an equal amount of crap to the doctors who think that because they DID spend a lot of money on software, that makes them special and their documentation better. Nope. They’re just wrong. Then I hear other people teaching that our documentation should “tell the story.” As one who gets to read this crap all the time, let me save you some trouble. We’re not reading your damned story. Not now, not ever. But there ARE certain and specific things we ARE reading. Some doctors document hardly anything. That’s a problem – maybe. Other doctors are just throwing as much crap as they can into their documentation with the hope that some of it sticks. I hope they didn’t spend too much on THAT software. So what is that that I’m looking for in your documentation? What ONE thing am I looking for on your FIRST visit that will help you TREMENDOUSLY with your future care? I’ll tell you… Next Time.
The Numbers Game
Even though Chiropractic has been around since 1895, it’s still a pretty young profession, in the grand scheme of things. While the rest of healthcare has embraced the use of numbers for years, chiropractic is still pondering the idea. While numbers aren’t the “end all,” if used properly, they can be of enormous benefit to chiropractors and our patients. When you go to a medical doctor, the visit often includes certain metrics of which they like to keep track: height, weight, blood pressure, temperature, pulse, respiration. Medical doctors often perform blood tests and a urinalysis on their patients, too, which helps them arrive at a diagnosis and enables them to track the metrics to see if the patient is improving or not with treatment. Even dentists use metrics. I was fascinated a few years ago when a visited a dentist friend of mine for a deep cleaning. His hygienist actually measured my gums and they were able to determine where I needed work and where I didn’t. So what about us? For all these years, chiropractors have relied on our patients telling other people how much better they feel with chiropractic. But… Numbers can make it even better. It’s one thing to affirm that the patient is feeling better. It’s another thing, though, to tell them that the intensity of their pain has improved by 18% and the frequency of their pain has improved by 24% since their previous visit. Chiropractors have been saying for years that we improve people’s function. We can take it even further by actually SHOWING our patients how MUCH we’ve helped them improve their function. The easiest and fastest way to do this is with outcome questionnaires. I saw you roll your eyes at me. We’ve got to make this easier than it is now, though. Some of you have been giving your patients the Neck Disability Index and Revised Oswestry Low Back Pain Disability Index. Let’s face it – your patients hate them and YOU hate them. I haven’t used either of those questionnaires in about 20 years. I switched to the Bournemouth Neck Questionnaire and the Bournemouth Back Questionnaire. Why do I use these? They’re only 7 questions each, which is 30% shorter and faster than the NDI and Oswestry, and they tend to be much easier and faster for patients to complete. There’s a great headache questionnaire that I use that can track how much functional improvement my patients achieve with treatment. There are outcome questionnaires for practically every musculoskeletal body part. Without overloading our patients with questionnaires, we can use the appropriate ones at the appropriate times and you’ll be amazed at how we can show how effective our treatment has been. When I show my patients the actual quantitative and functional improvement, they get EXCITED! If you want to get more referrals from medical doctors, we need to speak their language, which revolves around…NUMBERS. If you want to solve the “medical necessity” argument for Medicare and other insurers, document METRICS. If you want to show the world how effective chiropractic is at relieving pain and improving function, document METRICS. Gregg Friedman, DC, CCSP, FIACA Creator of The Bulletproof Chiro EMR
It’s Not About Insurance
I know, good documentation helps us get reimbursed better by insurance. I get it. But… It’s Not Just About Insurance. I graduated chiropractic college in the late 1980s. Back then, no one cared about our documentation. Ever. We would scribble meaningless stuff on ridiculous travel cards, but it worked for us back then. No one ever looked. Not even for PI. Then, one day, it changed. The health care world wanted more from us. The problem was, it took them YEARS to tell us what they really wanted. I want you to think about documentation differently. Instead of thinking of it like the worst and most time-consuming part of practice, let’s start thinking of our documentation as … How we communicate who we are and what we do to the rest of the world. Right now, the rest of the health care universe just doesn’t quite understand us or know what to do with us. We keep telling them how effective chiropractic care is and how cost effective it is, but we’re not communicating that very well. We’re just not speaking in their language. This is why exceptional documentation, in which we document certain metrics at the right time and in the right way, can finally show the world who we are. Many of us, over the years, feel uncomfortable with a report of findings. It often feels like a sales pitch. What if we can explain to the patient what is going on with the two most important things to them: pain and function? By documenting and calculating metric improvements in both, we can easily tell the patient what normal/ideal is and what they are. Then we can simply ask them what they want to do about it. We can tell them how much measurable improvement they’ve achieved and if there is more measurable improvement to be had. All based on metrics. No sales pitch. No charisma needed. Just numbers that are relevant to the patient. But I’m a chiropractor, too, and I know how many of us think. I’m the same way. First, this all sounds well and good, but if I can’t do it really quickly, I’m hesitant to change. Second, it’s got to be easy. Is this doable without technology? Of course, it is. But it’s going to take more time than you probably want to spend. Is this doable with technology? Of course, it is. But almost all software programs don’t do it. I do it. Every day. With every patient. And, for most visits, it takes me SECONDS. It doesn’t matter if it’s for a cash paying patient, a Medicare patient, an insurance patient or even a workers comp or PI patient. That should be irrelevant. Same exceptional documentation for all patients. It’s not just about insurance. Gregg Friedman, DC, CCSP, FIACA Creator of The Bulletproof Chiro EMR
The Shift
Major League Baseball has been analyzing data, called Sabermetrics, since the middle of the 20th Century. All year long, even in the off-season, baseball people are looking at data in order to determine a variety of scenarios that will help them get the best outcomes (wins). It’s gotten so crazy that there’s now a strategy called a “shift,” in which some of the infielders and outfielders shift more toward one side of the field because the data tells them that the hitter hits the ball to that side of the field a certain percentage of the time. In healthcare, there’s been a “shift” toward evidence-based healthcare. According to Official Disability Guidelines (ODG), the problem with evidence-based medicine (EBM) is that there is not enough of it. According to an Executive Summary from ODG, “randomized, double-blind, placebo-control clinical trials (RCTs), and meta-analysis of those trials are costly and time-consuming. They do not exist for many routine, low-cost interventions with little incentive to perform the study.” How does this apply to chiropractic? Rather than thinking about “evidence-based” chiropractic, let’s consider “outcomes-based” chiropractic. In fact, the entire healthcare system has begun a massive transition towards value-based care, in which health care systems will be rewarded not by how much treatment they provide, but how well it works. The beauty of this is…chiropractic works great. We just need to SHOW it works great. Don’t think of “outcomes-based” chiropractic as just an insurance thing, although it’s what ALL of the payors want. Instead, think of it as a way that we can finally SHOW the world how effective our treatment really is. We can accomplish this EASILY, by documenting certain metrics with regards to our patient care. For which metrics do we need focus? Believe it or not, Medicare answers that for us. They require that we keep track of just TWO things: Pain and Function. All of the payors want to see improvement in Pain and Function. Even our patients want to experience improvement in Pain and Function. We’re already doing it. Now let’s document it. Gregg Friedman, DC, CCSP, FIACA Creator of The Bulletproof Chiro EMR
