Identifying cases for physician review

The first step of an effective case review system is the ability to identify the appropriate cases for physician review. Without good case identification systems, case review can be inadequate or biased.

Cases are generally identified for chart review in two ways:

• Screening worklists
• Referrals

Screening worklist systems are based on information systems queries that look for a specific outcome (e.g., mortality, complications, and readmissions) or process (use of a particular medication for a specific condition) identified by medical records abstracting and coding data or through using data-mining tools to obtain further information from the transactional electronic medical record. Once identified, these cases then require review by the coordinators to determine whether the outcome was potentially related to physician care. This method can be productive if the data identifying the event have a reasonably specific serious outcome (e.g., mortality). When the event is identified by less-specific identifiers (e.g., general complication codes), these worklists can be quite time-consuming and may not yield useful review cases.

Referral systems identify cases using the organization’s occurrence reporting systems (e.g., incident reports from nursing, case managers, physicians, and patient complaints). To identify cases, referral systems are more efficient for coordinators than worklists because if someone takes the time to refer a case, it is more likely that there will be issues for peer review. To be useful for peer review, a good referral system relies on a strong reporting or referral culture to avoid event underreporting and the potential for personal bias by the referring individual.

So which method is best? Effective peer review programs typically use both. Because referrals are more efficient, it is important to communicate with groups who might refer cases (e.g., nursing, case management, risk management, medical records) to make sure that they are aware of the medical staff review indicators to maximize their use of the referral system. Because worklists are often more labor-intensive for the coordinators, they are best used selectively as a safety net for well-defined, important issues where it is either unlikely that the case would be referred, or it is important not to miss any cases with those issues.

Editor’s note: This is an excerpt from Peer Review Committee Essentials Handbook, Second Edition. Platinum Plus members can read the e-book for free here.