By Anne Federwisch, OTR
March 6, 1998

Outcomes: the clinical buzzword of the ’90s. Employers groups crave the data, accreditation organizations require it, and every discipline in health care is trying to measure its own clinical outcomes.

Yet no matter what the measurement tool, the results can only be as good as the information they’re based on. That often comes down to the quality of documentation in the patient’s chart. To borrow a phrase from the computer industry: garbage in, garbage out.

No single solution

Good documentation can be summed up in a formula, experts agree. Your notes are effective as long as you clearly state the goals and adequately note the progress toward potential outcomes, according to Patrice Spath, ART, a records technician who is a consultant with Brown-Spath and Associates in Forest Grove, Oregon. Spath has written several books on healthcare quality and outcomes management.

"There’s no ‘right or wrong.’ The right or wrong should be driven by the outcomes that are defined up-front by the caregivers and the patient," she said. A clear statement of those outcomes in the patient record also makes it easier for floating staff to clearly document progress.

Cindy Tanenbaum, MHA,OTR, a project manager with Washington, D.C.-area HMO Mid Atlantic Medical Services Inc., agrees. "When reviewing medical records [to approve or deny treatment plans], we’re looking for clearly stated goals and looking to see that the modalities documented on a day-to-day basis relate back to those goals."

No goal too short-term

Though many clinicians think about outcomes as long-term goals, such as "independence in self-care" or "return to work," there can be short-term and intermediate ones as well, said Patricia Rowell, PhD, RN, a senior policy fellow with the American Nurses Association. "Most people only focus on long-term outcomes, but every intervention ought to have some short-term outcomes you’re looking at along the way," she said. For example, a person with a total hip replacement might have a long-term goal of walking, but a short-term goal of weight bearing for increasing lengths
of time.

If there’s no goal for what you’re doing, Rowell said, you shouldn’t be doing it. She suggested that you ask yourself what you hope to achieve with a particular treatment. Progress toward that goal should then be documented.

Shortcuts?

Clinicians know that charting can be time-consuming. In Southern California, staff at Kaiser Permanente were spending more than 40 percent of their time on documentation, said Christine Zingo, MS, assistant medical group administrator with Permanente Clinical Systems Development for Southern California Permanente Medical Group in Pasadena, California. "Most of it was redundant," she said. So they implemented care paths and charting by exception, in which only deviations from the standard course of treatment are charted. "We basically said that the patient would be following the care path and everything would be normal unless you charted something that was a variant to it," she said.

Tanenbaum said clinical pathways can facilitate insurance companies’ approval of treatment plans and make it easier to see which outcomes are being achieved. Standard documentation when charting by exception includes the expected route of recovery, so outcomes are easily identifiable.

But not everyone accepts clinical pathways, charting by exception, or other formats. Rowell is skeptical, particularly of charting by exception. "My experience has always been that if you did it, you charted it," she said. "With checklists, people just whip down them It becomes so rote that you don’t think about it anymore."

However, she believes clinical pathways can be useful under certain circumstances. "I think that care maps, or care plans, or critical paths are very useful as long as they don’t become rigid," she said.

Why we have outcomes

Rowell said that even outcomes studies, which were adopted from industry, must be approached cautiously. "We saw that as being successful and tried to import it into health care. In many ways it’s been helpful, but in many ways it isn’t," she said.

In business, outcomes are used to monitor production to ensure a quality product. Yet health care is not as predictable. "[In industry], if my outcome is flawed, then I can go back and identify and control the process to eliminate the flaw," she said. "But the care of patients and their healing is very complex."

However, Rowell and others see a legitimate role for outcomes studies when data quality is adequate and conclusions are realistic. "It’s important to document outcomes to verify that your intervention was successful," Spath said. "Documenting functional outcomes and quality of life outcomes is also important in long-term treatment of the patient."

Some facilities use outcomes studies to prove the cost-effectiveness of their treatment. Such studies prove the worth of your treatment compared to competitors’, Spath said. If you don’t document outcomes, "then you can’t capture the data you need for bargaining and contracting purposes," she said.

Some ongoing efforts are within single disciplines. The University of Iowa College of Nursing developed standardized nursing language in the NIC (Nursing Interventions Classification) and the NOC (Nursing Outcomes Classification) to document a vocabulary that describes nursing work. For information, go to http://www.nursing.uiowa.
edu/cnc/.

Other efforts will create a single terminology across disciplines. One endeavor is SNOMED International (Systemized Nomenclature of Human and Veterinary Medicine). Its editorial board includes representatives from nursing, radiology, public health, ophthalmology, internal medicine, pathology, dentistry, and veterinary medicine. For more information, go to http://
snomed.org/.

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