1. Hess, Cathy Thomas BSN, RN, CWCN

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In my last column, 2018 Checklist: Organizing Your Department for the New Year (January 2018), we discussed the value of checklists and how they can be created and used as written guides to help your team meet key steps in compliance. In this column, we will look at the value of developing and managing your clinical documentation workflow. With so many clinical and regulatory requirements, it is important to take a "wound care workflow time-out" to ensure your documentation is up to date and compliant with the ever-changing rules.


Designing clinical and operational workflows requires review and customization of current clinical and documentation practices for an efficient outcome. Current practices include the operational processes for registration, coding, medical records, and billing as well as the cognitive workflow by the clinicians. Producing the right mix of operational oversight and clinical experience, grounded with a solid documentation system, will produce efficient business practices within your electronic medical record and optimal patient flow and care.


Investing time and expertise in developing appropriate workflows is imperative, as well as a team effort. When developing workflows, it is important to consider how the workflow design will affect documentation through managing messages, scheduling patients, checking in and rooming patients, conducting the patient examination, managing medications, and discharging the patient.1 This investment yields patient satisfaction, improved department processes to increase efficiency, reduction of errors, and improved outcomes, as well as patient and staff safety.


Let's take a look at the Merit-based Incentive Payment System (MIPS) and how the MIPS requirements impact your cognitive and clinical documentation workflows and ultimately auditing of the documentation. The electronic medical record workflows must be flexible enough to capture significant amounts of regulatory data for Advancing Care Information, Improvement Activities, and Quality. These reportable data serve as the basis for MIPS reporting. Therefore, it is important to understand the MIPS requirements, how these requirements impact documentation during patient-facing data collection on existing forms, and how the workflows guide policy for proper documentation and reporting processes.


Equally important to collecting MIPS documentation is understanding and proactively collecting the documentation necessary for a MIPS Audit. Let's review the potential for a Centers for Medicare & Medicaid Services (CMS) audit post-MIPS documentation and reporting. As stated in the Department of Health and Human Services' review of CMS's management of the Quality Payment Program:


In the final rule for 2017, CMS included program integrity provisions for both the MIPS track and the Advanced Alternative Payment Model track. In terms of the MIPS track, the rule addressed auditing and requirements for record retention. Specifically, according to the rule, CMS will selectively audit MIPS-eligible clinicians on a yearly basis and, if clinicians are selected for an audit, they must comply with requests for data-sharing and documents. To support such audits, CMS required MIPS-eligible clinicians and groups to retain-for up to 10 years after the performance period-copies of medical records, charts, reports and any electronic data utilized to determine which measures and activities were applicable and appropriate for reporting under MIPS. If a MIPS-eligible clinician or group is found to have submitted inaccurate data for MIPS, CMS indicated that it would reopen, revise, and recoup any resulting overpayments.2


At the end of the day, it is important to understand the meaning of the MIPS measures, documentation required to meet the measures, reporting options, and record retention for a potential audit.


Developing smart workflows within a practice takes time, patience, and a team effort. Ultimately, the smart workflow process will alleviate chaos in patient flow and lead to maximized efficiencies, enhanced clinical and operational quality, patient safety, streamlined documentation, and improved care coordination.


The healthcare industry is constantly evolving, and your workflow should guide your process. Examine your process as this is the key to a successful implementation. Look closely at changes required to adapt to new technology, regulations, processes, and procedures. Clinical and operational intelligence lies within your smart workflow.




1. How will electronic health records affect my workflow? Do I need to consider workflow redesign? 2013. Last accessed December 21, 2017. [Context Link]


2. Murrin S. Followup Review: CMS's Management of the Quality Payment Program. Department of Health and Human Services Office of Inspector General. 2017. Last accessed December 21, 2017. [Context Link]