Physician documentation and engagement

CDI specialists are told to keep physician engagement and education at the forefront of their efforts. Without physician buy-in, it can be challenging to run a CDI department at all, let alone achieve success. Yet physician engagement, or rather the lack thereof, is something most CDI programs struggle with on a daily basis.

A recent survey conducted by The American Hospital Association and Executive Health Resources (EHR) found that 98.5% of participants reported that their physicians could improve their documentation practices. Only 5% of respondents—out of over 1,000 surveyed nationwide, mostly CDI specialists— said their physicians were highly engaged, with no barriers preventing engagement in CDI. (Note—only 2% of the respondents were physicians.)

When asked about the root of their physician engagement challenges, respondents identified a number of issues, says Ginny Balla, MBA, documentation services manager at EHR in Newtown Square, Pennsylvania, who spoke about the survey findings and physician engagement in a webinar on April 16. The survey revealed three top barriers prohibiting physicians from being effectively engaged in CDI. Essentially, it pointed out that physicians are lacking certain things:

• An understanding of the importance of strong documentation. Physicians tend to document from the clinical perspective, Balla says, while the coding perspective is much more technical. CDI specialists exist to bridge that gap and help physicians understand how their turns of phrase translate to codes (and why it matters). However, the method by which CDI currently communicates with and educates physicians may not be the most successful. “[We need to be] working with physicians and educating why documentation is important for the physician themselves.”
• Time. Physicians are often focused on delivering care to the patient, and stopping to get documentation into the record isn’t always a top priority, says Balla. Moreover, physicians are focused on their current patients, and handling queries regarding a patient from 30 days ago can be frustrating.
• Interest—maybe. Many CDI specialists feel physicians are against CDI programs. But is the central issue lack of interest, or simply lack of awareness? “One of the things we hear over and over about CDI,” Balla says, “is that physicians view CDI as a hospital initiative, rather than something that the physicians need to be engaged in.”

The answer to these difficulties is to think like a physician and empathize with them, says John Zelem, MD, FACS, senior director of audit, compliance, and education at EHR. Appeal to your physicians’ strengths and weaknesses. Some of the most common educational approaches hospitals use to educate physicians—including posters, emails, and lectures—were deemed ineffective, the survey showed. Physicians document and think from a clinical standpoint. The trick is to look for solutions outside of the status quo, says Zelem. For example:

• Educate physicians in a way that works—not the way you’ve always done it. The survey found that real-time, patient-specific conversations are the most effective educational strategy to help physicians understand how they can improve their documentation.
• Acknowledge the limited time that physician resources can allocate to CDI. Physicians are busy, and very few physician advisors for CDI focus solely on CDI program effectiveness. Know the limits your facility has and adjust your strategies accordingly.
• Make sure physicians know there’s room for improvement across the board. No physician likes to be singled out, so it’s important that they understand improvement opportunities are a universal theme in CDI.
• Get a physician advisor on board, if you can. They can help bridge the gap between physicians and CDI specialists, and can be more effective at getting physicians to work with CDI programs, Zelem says.

Technological trouble
Technology also seems to contribute to physician engagement challenges, says James P. Fee, MD, CCS, CCDS, vice president for Huff DRG Review. “The physician’s biggest complaint is ’I just want to take care of patients,’ ” says Fee. “Time spent in front of computer is exceedingly disrupting the coveted physician-patient relationship and bedside care.”

CDI professionals sometimes view technology as less of a barrier in preventing proper documentation than physicians do. The reality, Balla says, is that EHRs do not engage physicians but simply automate the documentation process. Some EHRs turn a patient encounter into an exercise in physician data entry. A system aimed at organizing physician notes may actually encourage erroneous copy and paste, not quality documentation. From the CDI perspective, EHRs standardize required details and stratify clinical information; from a physician standpoint, however, the technology does not elevate documentation standards or modify physicians’ thinking. As a result, physicians ask CDI specialists to tell them what to say or what boxes to check, Balla says.

While relatively new in healthcare, EHRs still aren’t tailored for the physician as the end user, says Karen Chase, MS, BSN, RN, CCDS, assistant director of CDI for Stony Brook Medicine. Eventually this will change—EHRs are currently being modified to include forms that will engage physicians and help provide the proper language needed for documentation, as well as make use of computer-assisted coding to look at clinical indicators and push forward diagnoses that are important to the patient. But as of now, they’re considered a hindrance to physicians.

“There is a frustration element,” Chase says. “Physicians say, ‘I’m doing everything I can and you still want more. Why don’t you build the system to help me?’ Once developers do that, they’ll get more physician engagement.”

As for technology, try getting physicians involved in creating templates  and improving the electronic record system, says Sharme Brodie, RN, CCDS, CDI education specialist for HCPro in Danvers, Massachusetts. An overwhelming number of physicians feel that there are too many hard stops and soft spots they have to answer; that there are way too many drop-down menus and check boxes. By giving physicians an opportunity to get involved, CDI specialists hear from them directly regarding what they want and need from the EHR.

“I do think they’d respond and want to get involved—physicians love to teach,” says Brodie. “It’s all in your approach. Make it seem like the end result will be something both CDI and physicians will benefit from. I think generally physicians want to help out.”

In summary, physicians will respond to direct communication. By adjusting CDI efforts to fit their needs and strengths, physicians, in turn, will be more apt to work with CDI specialists. Here is an example of a documentation review process that incorporates effective physician discussions:

1. Review: Determine if greater specificity is needed.
2. Substantiate: Clarify if a query is valid or needed.
3. Engage: Interact directly with physicians one on one to gain clarification in the documentation and provide case-specific education and feedback. If your program does not currently have a physician advisor, consider working with management staff to hire one. Make sure to follow ACDIS/AHIMA query guidelines and recommendations to avoid leading the physician.
4. Document: Provide a written summary of the physician conversation so that all queries—even verbal ones—are tracked effectively.

Facilities can improve physician support for CDI efforts by engaging them from the get-go, communicating directly with them, employing their assistance in EHR and query efforts, focusing on their clinical needs, and simply asking them how they prefer to be communicated with.

Physicians are humans too. Empathetic CDI specialists just need to engage them to make sure educational efforts and review processes work for everyone involved. Physicians face numerous daily challenges, not least of which include caring for their patients. Therefore, CDI can become a lower priority for them, says Zelem.

“I believe that most physicians really do want to do the right thing,” he says—and CDI staff need to be there to help them do that.