Fall 2009

2009 Documentation of Care review reveals three areas for improvement

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) recently conducted the 2009 annual medical record review of primary care physicians (PCPs) participating in our HMO network, Health Options, Inc. The monitoring of documentation of patient care takes steps to assess and improve medical records--keeping practices to promote patient safety and improve continuity and quality of care.

The program is consistent with efforts to respond to customer expectations and accreditation requirements by the National Committee for Quality Assurance (NCQA), Agency for Health Care Administration (AHCA) and Centers for Medicare & Medicaid (CMS). A statistically random sample of Health Options HMO members was pulled from the statewide Health Plan Employer Data and Information Set (HEDIS^®) dataset. A comparison over the last three years is shown on Table 1.

Our 2009 Documentation of Care review identified three areas of opportunity for improved compliance. The three indicators were:

Documentation for 14 years of age and older inquiry/counseling regarding alcohol/substance abuse in baseline history or physical

The best chance for a physician to detect a problem with alcohol and drug abuse is in the context of routine medical care. Screening provides an opportunity for the clinician to intervene early and impact a patient's overall health. According to National Institute on Drug Abuse (NIDA) using the 5 A's of Intervention (Ask, Advise, Assess, Assist and Arrange) can be a useful framework in encouraging patients to quit drugs. You can find more information at www.nida.nih.gov.

Pediatric and adolescent immunization records complete and up to date for children 16 years of age and older

The physician office documents if immunizations are up-to-date and requests the parents to provide a copy for the medical records. Physicians are encouraged to enroll in the Florida State Health Online Tracking System (SHOTS) program by clicking on the link at the Availity website (www.availity.com) to track and secure a complete patient immunization file. Refer to the current Centers for Disease Control and Prevention (CDC) immunization schedule at www.bcbsfl.com, by clicking Physicians & Providers, Medical Information, then Preventive Services Guidelines.

Advance Directives

Federal and state law regulations mandate that HMOs require contracted providers to document whether or not HMO members 18 years of age and older have an advance directive. A yes or no is sufficient and should be found at an easily accessible location in the medical record. It is recommended that practitioners place a question about the existence of advance directive on their new patient history form or registration form.

The Documentation of Care review showed significant improvement in five indicators from the previous year as shown below: 

Your help in implementing change is critical to facilitating improved communication, coordination and continuity of care. If you would like a copy of the Documentation of Care tool packet, please call Joanne Keenan at (800) 555-8228, ext. 87329.