Q&A: Query escalation in the remote world

Q: I have a question about provider education and query escalations in a remote world. What is your provider education process? Are your frontline CDI staff facilitating regular provider education or do you have a designated CDI physician educator or team of CDI that facilitate on a regular basis? How is this being facilitated (i.e., in person, through email, WebEx)? Also, when it comes to query escalations or education related to queries, how are your providers contacted and what’s your timeframe for escalating?

Response #1: At my organization, we do provider education remotely via Webex, on an individual basis when a physician is hired into the health system. We have one dedicated person for this. The administrative assistant coordinates scheduling of the meetings and sends the WebEx invite out with CDI educational materials that will be covered during the call. Depending on specialty, the calls range from 15 minutes to one hour. We focus the orientation to each specialty, their shift working, and role: admitting, rounding, consulting only, etc.

Query escalation has recently taken a shift for us due to a change in the physician advisors within the system. Currently, our staff give the provider queried 48 hours. If there’s no response after 48 hours, the case/query gets sent (via email) to the physician advisor on for the day who reviews and then determines the next step (usually, reach out to the provider via email or have a conversation for education, etc.).

Response #2: My CDI team is mostly remote since COVID (pre-COVID we were only remote one to two days per week). I say mostly because provider education. My team has always educated the three hospitalist groups (about 150 providers total) who provide care in our system on a monthly basis (one topic per month, along with any personalized education organized by our staff or based on reporting). We did toss around the idea of virtual provider education in the earlier days of COVID, but it just wasn’t feasible due to the providers’ schedules and office set up in the hospital.

During COVID, we did take some time off from personalized education and sent educational tip sheets via email to our hospitalists and their group managers. Once we were cleared and comfortable to return onsite, we implemented a new rotational education plan. Now, the teams rotate through the hospital four times per month to present and discuss the monthly topic. This schedule works best to ensure we have time to meet with each provider in 15–20-minute increments. Some campus teams have six CDI specialists while others may have four, so some staff do go onsite more often than others, but we don’t really have complaints about that (thank goodness!).

The providers are made aware of the days we will be on campus in their office, thanks to the assistance of the office manager, and they pop in when convenient for them. Some end up getting one-on-one education, while others end up receiving education in small groups, depending on how many providers are in the office at a time. This process has worked well for us so far. The staff track education sessions on spreadsheets by campus. We also publish a quarterly newsletter on our department website on the system wide intranet, along with our monthly education tip sheets. Some providers access this information, while I am sure others forget it exists.

Our CDI specialists send query reminders on pending queries every Friday. We send one reminder per query, then hold the providers accountable for answering them. Queries were added to our HIM deficiency process about two years ago, which means unanswered queries hold the same weight as missing operative notes, history and physicals, discharge summaries, etc. Currently, our HIM departmental policy allows providers 30 days to complete these required documents. If any of these are left incomplete after 30 days, the provider is added to a suspension list and receives a personal phone call from a physician advisor. We typically see queries answered within 24 hours of receiving the pre-suspension list from HIM. Our advanced practitioners are not included in this process, however, so we have a different escalation for them. After 30 days, we reassign the queries to the provider responsible for the advanced practitioners and can include the physician advisor for assistance, when necessary.

Response #3: At my organization, we round within the ambulatory and inpatient departments, helping clinicians onsite, as they are working.

When a query is sent, the clinician has three business days to respond. A reminder goes out the fourth day if we have not heard from them and then we give them two business days to respond. If they do not respond, we complete the chart without updates. The non-response if factored into the clinicians’ statistics.

Response #4: I have a team of fully remote and hybrid, but I am fulltime on campus as the leader and provide all of the education/contact with providers when needed. The other avenue is that when a hybrid remote (the CDI specialist comes in once every three weeks), they will also round and touch base with providers for any query discussion needs. We have a physician advisor that helps when I need to escalate an issue, and he usually texts or has a face to face with provider.

Response #5: We have a CDI educator who coordinates and develops all education, which is delivered mostly virtually. The CDI specialists from each facility are asked to attend either in person if they live close by or virtually to address any site-specific questions. This process has been going on for over eight years, but the educator was put into place to coordinate the efforts in late 2022. We were using a committee, which consisted of CDI associates previously. We contact our providers either via email, phone, or if they really need guidance, we have physician advisors at all sites.

Response #6: Our provider education is done primarily by our CDI physician advisors. There are times that I do some of it as the CDI manager, but most of it is now done by them. The provider education is done in a variety of ways. The physician advisors do more informal educational sessions in our hospitalist huddles. They attend various committee meetings to provide education. Most of these are done via Microsoft Teams meeting, but some are in person. They have even gone to physician’s offices to provide education. They also do midlevel education. These tend to be done in person but can be done virtually if needed. I think the bottom line is, wherever they can get in front of the providers, they are willing to provide the education in any setting.

For our escalation process, they are using a secure texting system. The CDI specialists will also reach out to the providers via the phone, especially if it is a challenging query or the provider has had a pattern of having some difficulties answering queries. A lot of one-to-one education is provided during the escalation process.

We allow 48 hours before we escalate a query to the physician advisor. We will get our IT physician liaisons involved if the issue is that the provider just does not know how to answer a query in EPIC.

Response #7: I have created a CDI educational course that is composed of four weeks and seven modules plus a practicum. The goal is to engage our residents, fellows, and attendings and get their buy-in for the betterment of query response rates and improve our documentation and feedback. Some of our residency program directors scheduled us (me, the physician CDI course director) to give the course among their graduate medical education pre-scheduled CEU series. Other residency directors preferred to incorporate this course early on at first- and second-year residencies plus their clinic hours for superior hands-on documentation. Residents and fellows became superusers and physician champions upon graduating this course once they understood the importance of proper data profiles and case mix indices.

Our query response rate thereafter improved to an average of 90%-95%. Escalation is rarely needed due to the success of our outcomes, but when we need escalation, we escalate to department chairs 48 to 72 hours after the query is sent since we anticipate incorporating our responses “concurrently” prior to patients’ discharge.

Response #8: Our team does both remote and in-person education and escalations. We strongly believe that a hybrid model is necessary for developing and maintaining physician engagement with our team and program. We also have all members of our team participating in education and escalation processes as the discussions that are needed to maintain our response and agreement rates are best in the context of provider relationships.

With that said, our sites have anywhere from one to 20 CDI specialists so this may look different at various sites. We also recognize that newer CDI specialists may not initially be ready to “go solo” on some of these missions. We have physician advisors who help to facilitate escalations either in person or through the EHR secure chat or emails. Using a multipronged approach is usually the most effective. The clinician culture and the organizational support for CDI heavily influences clinicians’ willingness to engage in both education and partnership with the program.

Response #9: A provider escalation process is a good vehicle to have in place when there may be physician engagement challenges as seen in lower response rates. In this case, I like to engage the provider’s direct superior, supervising physician, medical staff office manager, or operations director to further support the CDI initiative. After escalation to the direct superior requesting assistance in engaging that provider, we usually have success. This also helps prevent future delays from the same provider, as they are not eager to receive this type of repeated communication from their supervisor. We typically escalate after the second or third attempt, not to exceed 20 days of being outstanding. Most documentation needs to occur within 30 days after discharge. 

Next, provider education should serve the purpose of effectively delivering education to the provider. I encourage CDI specialists to be flexible around what the provider indicates as the preferred method of receiving this education. Some may prefer a phone call while others may prefer Webex, email, or in-person. One shoe doesn’t fit all. It is also important to consider that not all facilities may be equipped with a physician educator, so I encourage all CDI specialists to build rapport with the providers so that they could deliver education when needed. If provider education is beyond the comfort level of some CDI specialists, then I would recommend identifying certain team members who are comfortable with delivering education, such as a team lead, CDI manager, or a seasoned CDI specialist. It is also useful to have education templates to ensure consistency among your team’s delivery.

Response #10: Our team is hybrid and rotate to campus with a goal of ongoing presence and building relationships with the providers. A normal rotation schedule is one day per week onsite and four days remote.

We have seen that a layered approach to education seems to be best as it’s hard to find one education strategy that works for all providers. Our process includes:

• CDI leadership team presents education topics at hospital medicine meetings
• Physician leaders share education topics with the provider groups
• Frontline team does one-on-one education with providers when onsite, e.g., in physician lounge, when rounding on units, etc.
• Our corporate CDI team supports us with flyers that are distributed to our providers and CMEs are offered for completing the education

We have an escalation process that the team uses when a clarification has not been responded to in a 24–48-hour timeframe. We utilize the chief medical officer (CMO) for each campus to assist in the process. We emphasize to the team this is not to be used as an “easy button,” rather we want to be able to show that we have first gone over and above with our efforts to get a response. The CMO usually just reaches out and nudges the provider and that seems to do the trick. We do not have a high number of escalations.   

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.