Tip: Engaging your physician advisor

by Howard Rodenberg, MD, MPH, CCDS

Let’s say you’re a lonely CDI program looking to take that next step, to meet a physician advisor for a long term-commitment. You’re not finding anyone of interest on “Documentation Tinder,” but just maybe that profile on CDImatch.com looks promising. How do you know if he or she is the one?

The process of engaging your physician advisor starts with selecting the right candidate (Of course, I am the gold standard. But I digress). The biggest quality you need to look for has to do with attitude. The intellectual skills, the mechanisms of coding and the principles of CDI, are things that people of all stripes can learn. With a physician advisor, however, you also need someone who is not just outgoing, but is also able to communicate information in a relevant and focused way. Being able to talk to people and to do so effectively are two very different qualities, and it’s important to recognize that in the interview process.

I’m split on the issue about whether your physician advisor should come from within or outside of the institution. Familiarity may enhance access and credibility but potentially at the expense of prolonging traditional thinking. Conversely, hires from outside the organization bring new ideas but may have problems getting a foothold. If that person does come in from the outside, it’s important that they receive immediate and visible support from the highest levels of hospital and medical staff leadership.

Given the right personality and commitment, I don’t think the physician advisor’s medical specialty makes that much difference in the long run. However, I’m starting to think that there may be an advantage to recruiting someone from a surgical background, at least early on in the CDI program. Many times the biggest impact we can make on CDI is within the surgical specialties, and surgeons tend to be a pretty clannish bunch. It helps to have someone who can speak their language (even the four-letter words). Internists may not document optimally but they do tend to document more, so you may have a little head start and less of an uphill battle with them. I may be biased, but I think an ER background is a good choice, because we learn to speak everyone’s language and to communicate what we need in sound bites.

It’s critical to note that CDI is not a retirement job. Many physicians want to slow down at a certain age, and they see administrative jobs as one way to do so. I would be lying if I didn’t say that after years of doing 15 years of 12-hour ER night shifts a month, it’s really a joy to live like normal humans do. But some physicians may see this as a way to put their feet up, sign a few papers, and be done with it. They don’t understand or anticipate the level of activity required to truly make a CDI program work. I think you need to get a good sense of how your candidate perceives this job in the context of his or her career path, and insure that expectations for performance are identified up front.

Now that you’ve got someone on board, how do you get them up to speed? I would suggest that a new physician advisor, fresh to the field, attend an ACDIS Boot Camp of some sort. That said, I don’t think the CDI team should expect the physician advisor to come out of any boot camp experience with a blueprint to do the job, nor with a comprehensive knowledge base. Instead, he or she will likely wind up with a thousand ideas jotted down on sticky notes and in the margins of handouts. The physician advisor will ponder these materials for a few weeks, and as he or she learns more about their specific CDI program and individual system, these ideas will start to crystalize into a game plan. I think if it’s possible, I would also send a new CDI physician advisor to a utilization management (UM) boot camp as well. The two areas are closely aligned enough that the methods and goals are often intertwined, and learning the language of UM is critical to understanding the true effect CDI can have on the overall organization.

Talking with colleagues in ACDIS is a great resource as well (That being said, I plead guilty to being a bad networker. I’m the guy who always has to take a phone call right when the “icebreakers” start at the beginning of a meeting. “Sharing” drives me crazy). But I think the best networking you can do is talk to physician peers, the clinicians at the institution the CDI program and its physician advisor serves. Ask them:

• What do they know about CDI?
• What do they want to know?
• If they can accept it as a necessary evil, what’s the best way to work with them? Phone? Text? Email? Live rounding?

This is the best kind of collaboration you can find, and will do the most to enhance the physician advisor and CDI program’s level of service.

Can a physician advisor perform the role for both UM and CDI? I think that at a relatively small hospital a physician advisor could probably pull it off, but I’m not so sure that situation works as well for larger or multi-campus institutions. While there is overlap in general principles, the skill sets for focused record review related to each of these roles are different. CDI lives in a clinical world of trying to make the vague more specific while UM is more of a numbers and criteria game. CDI works with providers while UM tends to work more with case managers. I would think it would be difficult to make the mental jumps from one role to another and do either particularly well in the face of high patient volumes and an expansive medical staff.

Physician advisors need to be comfortable with not only developing queries and facilitating education, but also with those difficult conversations with providers regarding their documentation habits. Doctors tend to be a collegial bunch. There is specialty rivalry, of course, but doctors generally don’t want to sit in judgement of one another or tell someone else they’re doing something wrong, especially if it’s an issue outside of their own specialty practice. It may also be that a physician advisor, especially if they’ve been on staff for a long time at a smaller hospital, don’t want to antagonize their colleagues who may also be friends or even practice partners. Plus, the physician advisor may just not have a personality that’s willing to engage in the way that benefits the CDI team.

That being said, how do you push your physician advisor along? I think you need to change the context in which the difficult conversations occur. Recognizing that doctors hate administrative “hassle,” it would make sense for the physician advisor to approach the clinicians not with, “Why didn’t you do the query?” but “If you do these, the queries go away.” The new context means the physician advisor is there to help, not provoke a confrontation. The other argument you can make effectively and non-confrontationally is that while the increased revenue from enhanced documentation doesn’t go to the doctors themselves, it does go for paper and pencils and nurses that are needed to do the work of patient care. This works much better in smaller community hospitals where you can make it an issue of hospital survival.

Throughout the onboarding process the CDI physician advisor needs to keep a sense of humor about all this. A lot of things in the “Coding World” and “ICD-10-Land” don’t make sense. You can get mad about it and spin your wheels, or you can acknowledge the absurdity and find ways to work around it. And, if you happen to work in Jacksonville, Florida, as I do, at least once a week you can have lunch at the beach. That works wonders for perspective.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. To listen to an ACDIS Radio featuring Rodenberg, click here. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.