Physicians are fervent believers in the goals of clinical documentation initiatives, and they want a CDI at their hospital to work — at least in theory. Trouble is, with many hospitals still in the early developmental stages of their CDI programs, physicians are seeing little net benefit for their individual practice or their patients, even if a CDI is meeting the goals of system administrators. The return on investment for the physicians' time just isn't there yet.
From the physicians' perspective, a CDI is really for the hospital and its database. Physicians figure, "The coders will query me anyway. Whatever I document today won't help me with today's patients. Besides, I really don't understand how my documentation turns into coding." There is some legitimacy in their reasoning, but they still need to document.
Tactics to Promote CDIs
Hospital administrators can provide better support to physicians so that they engage more with a CDI. The following are some practical steps:
Provide the physicians with real-time information while the patient is present. It helps if physicians receive relevant, actionable information as soon as they enter documentation. Patient data may live forever in the database, but as a treatment tool, it has a short shelf life. Doctors want their clinical data input processed and analyzed while it is fresh enough to make a difference for patients under their immediate care.
As an example, hospital-based physicians would benefit greatly if their documentation of diagnoses and comorbidities would instantly translate into a predicted or preliminary geometric mean length of stay. This, in turn, would present a preliminary case mix index, to be reviewed (and, if necessary, queried) by the CDI team. This software capability is already available and in use, enabling physicians to develop their care plans quickly while keeping better track of costs in real time. That is how you answer the "What's in it for me?" question that physicians often ask silently or aloud. Do this for your physicians and watch them improve their documentation.
Physician leaders at the facility must be visible, vocal and united in efforts to promote CDIs among the medical staff and the administrative team. Creating a culture of documentation requires active engagement from the clinical leadership team. A CDI presents an excellent opportunity for the chief medical officer, vice president of medical affairs, medical directors and other clinical titleholders to bolster their leadership, demonstrating their commitment to CDIs through recognition of best practices, participation in CDI training sessions, and setting the right tone and example through their own clinical practice.
Without support from physician leaders, exhortations to engage with CDIs are likely to fall on deaf ears. All physicians and practice groups at your facility should be expected to demonstrate to their physician leader how CDIs are built into their daily workflow to ensure consistent and accurate clinical documentation.
Physicians must be continually educated to view CDIs as first and foremost a quality mandate. CDI training has to be delivered in such a way that the physician internalizes the message and integrates a CDI into the daily workflow. Keep in mind that most clinicians had little if any exposure to a CDI as part of their medical training. There will be a wide range of knowledge and experience with clinical documentation, requiring a flexible and individualized CDI education program.
The advent of ICD-10 in October 2015 is a timely opportunity to relaunch a CDI education program, as it will stimulate physician engagement in a forceful, if not entirely positive, way. It's a chance to educate physicians on two important and closely linked initiatives at the same time.
Encourage active engagement and team building between the physicians and the CDI team. After all, coders sometimes find themselves at odds with physicians over a variety of matters because of physicians' lack of knowledge or expertise in proper coding practices.
The rules of coding do not always comport with the physician's view of the clinical situation. For a CDI program to be successful, both physicians and coders must exhibit a close clinical working relationship built on a culture of partnership and mutual respect. Moreover, this attitude should be noticeable and apparent to all players on the medical and administrative staff of the hospital. A CDI team that is well-integrated with physicians will have taken proactive steps in training and education, which will result in fewer retrospective queries.
Formalize the hospital's expectations by articulating physicians' responsibilities in attaining CDI goals. Spell it out clearly in standardized contractual language. Add it to physician employment agreements as well as agreements between the facility and the practice group. This is not about adding extra work but about fulfilling a basic part of job responsibilities for the patients' benefit.
Connect the CDI effort to the hospital's overall physician engagement and development program. Physician-CDI engagement has the best chance for success if there is a strong culture of engagement between physicians and your hospital on all levels — clinically, operationally and financially. A facility that is effectively engaged with its physicians can improve documentation through better working relationships with the coding staff, more thorough physician training, more physician attention to the mechanics of documentation, and better commitment to documentation as part of the daily workflow. Indeed, good clinical documentation should be viewed as a hallmark of good engagement; one cannot exist without the other.
Making the Connection
Physicians readily acknowledge that at its heart, documentation is a quality issue and, therefore, they must be in the forefront of a successful CDI program. The challenge is to get the physicians to connect the dots and put themselves in the center of the action in the quality-documentation dynamic.
The enormous benefits of a CDI cannot be fully realized without committed engagement from the physicians. However, the needed engagement will not occur unless hospital administrators, together with clinical leaders, bring about meaningful change in physician behavior and outlook. Physicians will become more engaged in CDIs when they have more proactive support and direction from the hospital. Let us do more to help the doctors help their practice and their patients more effectively.
Todd J. Kislak is the chief development officer for Hospitalists Now Inc., a physician services company based in Austin, Texas.