Historically, healthcare organizations have been operating under the belief that when it comes to communicating with physicians, more is better. The tendency is to “cover the bases” and make sure they are sent details on everything, just in case. This is not effective. More is simply more. At high-performance institutions, teams carefully scrutinize the message and the target audience. This discipline demonstrates respect for the physician’s time, knowledge of their professional specialization, and an understanding of their needs.
Often the number of department within an organization sending messages to practices confounds the “relevance” challenge… A useful first step is to audit the current volume of outbound messages, the relevance for the practice, the timing and overlap… Next, find out what doctors need to know. Too often, physicians are not asked what they want or need to know; instead messages are “pushed out” with little regard for the physician’s needs.
Editor’s Note: This excerpt was adapted from The Complete Guide to Physician Relationships: Strategies for the Accountable Care Era, by Kriss Barlow, RN, MBA.
by Melinda Tully, MSN, CCDS
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close. In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.
Then, starting in 2014, base payments will depend on the outcomes of the care documented.
So how do we shape up before we face even bigger federal cuts? Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.
I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately. For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.
Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.
The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way. This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.
Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.
For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population. These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers. The best part about this customer’s success is they have improved their documentation and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future. [more]
Engage the physician in query development
Experienced CDI programs often suggest that the best form of physician education is physician involvement. The earlier physicians get involved in the development of the CDI program, the greater their investment becomes. With the program parameters established, CDI staff can turn their attention to the development of physician query templates.
The medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms. For example, many facilities have clinical guidelines to help determine types of congestive heart failure based on recent medical literature and as supported by the cardiology department.
The American Hospital Association’s Coding Clinic for ICD-9-CM supports the development of guidelines for querying physicians. It states:
Facilities can work together with their medical staff to develop facility-specific coding guidelines, which promote complete documentation needed for consistent coding assignment. … These facility guidelines must not conflict with the Official ICD-9-CM Guidelines for Coding and Reporting developed by the Cooperating Parties and additionally they should not be developed to replace the physician documentation needed to support code assignment.
Further, the ICD-9-CM Official Guidelines for Coding and Reporting state:
A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized.
Physicians are not the enemy. Despite how busy they are, they want to comply. They want positive feedback. They want to do the best job they can for their facility and, perhaps more importantly, for their patients.
Editor’s Note: This post is an excerpt from The Physician Documentation Improvement Pocket Guide instruction manual. The Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP, is a tri-fold laminated card which comes in packs of 25, to assist CDI specialists in their physician education efforts.
By Heidi Hillstrom MS, MBA, RN, CCDS
As a 10-year veteran of a successful CDI program, I am accustomed to being asked, “How did you build your program?” My response invariably is how vital it is to bring your physicians on board.
Before you respond, “But you don’t know how difficult this is with our physician group!” Or, “Get real Heidi! That isn’t going to happen here!” Let me assure you that obtaining physician support for CDI efforts is definitely achievable.
It all hinges on relationship building. This didn’t happen overnight, for us of course. Once they understood there was no implied criticism of their documentation ability or attempt to tell them how to practice medicine, a lot of the initial hostility disappeared.
First, be visible to your doctors. Whenever possible, perform your reviews on the units. Greet them by name. Don’t be afraid to enter into general conversations that are occurring. It doesn’t have to involve documentation. The performance of a favorite sports team can be a great conversation starter. During these conversation moments, you will have opportunities to discuss clinical documentation, but keep it brief and to the point.
Second, be respectful of your physicians’ limited time. I requested to be included on the agenda of their staff meetings. Personally, I never tell a physician I’m there to provide them with “documentation education.” They are well educated, and this can be perceived as being condescending. Instead, I tell them that I am here to provide them with the most recent documentation “information” that impacts their practice.
I found formal power point presentations tend to lose their attention fairly quickly. Rather I present an informative agenda tailored to their particular specialty and encourage open discussion. I ask them to share their expertise in understanding the clinical indicators for a diagnosis. This is really where the collaboration begins.
Be prepared to listen to their frustration with the documentation process without becoming defensive. A little empathy can go a long way. It is crucial to follow up with any questions they may have. Finally, ask them for their input on how the CDI clinicians can improve their communication process.
Once I became more than a faceless documentation query, building a relationship became much easier. Now, I am often approached on the units and contacted, by physicians, with additional documentation questions and or concerns. Friendly conversation became natural. My template or note became a message from me. My queries are more likely to get a response. In fact, once the physician and clinician relationship grew and clinical documentation is now a collaborative effort, I am often greeted with, “Hey Heidi, is that question for me?” once they saw a query form in my hand.
In closing, I am pleased that I have gone from a physician fiend that they avoided to a friend who physicians seek out.
Editor’s Note: Heidi Hillstrom, MS, MBA, RN, CCDS, is Clinical Documentation Manager at St. Luke’s Hospital in Duluth, MN. Contact her at firstname.lastname@example.org.
Editor’s Note: Over the coming days and weeks, we will post a series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. Today’s post features James S. Kennedy, MD, CCS, ACDIS Advisory Board member and a director at FTI Healthcare in Brentwood, Tenn. Kennedy will co-present the ACDIS pre-conference event titled “The Physician Advisor’s Role in CDI: A collaborative approach for success.” The two-day session takes place Tuesday and Wednesday, May 8-9, 8 a.m. to 4 p.m.
Q: What role should CDI physician advisors play in audit review and data analysis?
A: Clinical Documentation Improvement (CDI) physician advisors are critical to the entire process of ensuring the integrity of coded administrative data (ICD-9-CM and CPT) and its application to physician and hospital quality and cost efficiency measurement.
CDI is the process of preventing and reconciling inconsistent, incomplete, imprecise, conflicting, or illegible documentation to bridge the gap between treating physicians and coders. Physician advisors must be able to analyze data derived from these codes to target their efforts and should review the results from documentation audits as to hone their message.
Examples of these activities include:
- Data Analysis: ICD-9-CM coded administrative data is primarily used to determine, measure, and report severity and risk adjusted outcomes and cost data for various metrics. These include cost, length of stay, complications, mortality, readmissions, and the like.
Risk and severity adjustment means that the actual metric being measured (observed) is compared to the likelihood of that metric occurring (expected). CDI ensures the integrity of the expected metric, usually increasing it since many clinical descriptions are incomplete or imprecise, thus reducing the risk-adjusted metric.
Take for example the Colorado Hospital Report Card. Note that Colorado reports an actual mortality rate and a “risk-adjusted” mortality rate. There are instances when the risk-adjusted mortality is less than the actual mortality since the death rate is less than expected. There are others, however, where the risk-adjusted mortality rate is higher than the actual.
Another aspect is measuring complications of care. Some facilities code incidental serosal tears as “accidental lacerations.” Physician advisors would want to analyze Patient Safety Indicator data at their hospitals (e.g. from Thomson-Reuters, the Delta Group, and the like) to determine if the data driving these metrics is accurate.
For example, look at the website “CareChex,” a division of the Delta Group, to see how it ranks overall surgical care in Chattanooga, Tenn.
Physician advisors should partner with their chief quality officer to learn how these risk-adjustment methodologies work and how the definition, diagnosis, documentation, and coding of these conditions factor into them.
Armed with this information, the physician advisor can help develop systems that work with providers to accurately capture these metrics.
- Chart Audit: Physician advisors are integral to the chart review, given that they recognize the clinical scenarios that are often not documented completely and precisely. Imagine a patient admitted with a pH of 7.02, pCO2 of 100 and a pO2 of 40 and stupor requiring mechanical ventilation but only described as respiratory insufficiency with CO2 narcosis. This patient has acute hypercapnic respiratory failure and could potentially be labeled as having a metabolic encephalopathy. The physician advisor recognizes these scenarios and can help concurrent reviewer and coders recognize the circumstances whereby query would be prudent.
Q: How can a physician advisor help achieve buy-in from the medical staff for CDI efforts?
A: The best ways I know to achieve buy-in from the medical staff are to:
- Make CDI an academic exercise, emphasizing the definitions of clinical conditions. These can include:
- Transient ischemic attack versus stroke. Note that the 24-hour time frame is completely eliminated.
- Acute myocardial infarction vs. accelerated angina. Note the critical role of properly calibrating troponins and equating elevated levels with “symptoms of ischemia.”
- Acute kidney injury. Note that it is only a rise of the serum creatinine of only 0.3 mg/dl
- Ask the quality officers of your hospitals to generate individual physician reports regarding their own cost efficiency and outcomes, outlining the actual and the expected outcomes. Should a physician see that their expected mortality rates is higher than expected and that CDI is a strong solution addressing the “expected” component, his or her participation and interest is likely to increase!
Q: How involved should the physician advisor be in the day-to-day operations of the CDI program?
A: Given that most physician advisors have their own private practices, they do not need to be involved with the direct day-to-day operations of initiating queries. They should, however, be available at designated times to support concurrent reviewers and coders regarding the clinical circumstances assessments of clinical situations requiring query and to aid in their construction.
If at times a physician does not respond, the physician advisor may potentially have a collegial conversation about a query. One must be cautious, however, to frame this conversation about defining a patient’s condition without putting the physician on the defensive.
One of the fun things a physician advisor can do is support the development of the electronic medical record as to make the capture of complete and precise documentation less onerous to the practicing physician.
Q: What are you looking forward to most about this year’s ACDIS Conference?
A: Wow….what’s not to look forward to? ACDIS is everything a CDI professional, coder, or physician advisor would want—clinical conversations, problem solving, medical informatics, and collegial interaction with like-minded individuals working to solve the challenges we all share.
It’ll be great to be with old friends and make new ones! Not to mention that all this occurs in downtown San Diego, in a phenomenal setting (this is a beautiful hotel), right next to Balboa Park (let’s rent a bicycle and ride!) and close to Sea World, the ocean, and all that makes southern California great!
I must say, however, that the most anticipated event for me is the Physician Advisor pre-conference where Dr. Trey LaCharité and I spend two days training physicians from all over the nation to understand and embrace CDI principles.
I feel that this contributes to the professional practice of medicine and empowers physicians to successfully negotiate healthcare reform. Needless to say, I’m very excited about the conference!
Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.
Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.
Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)
Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.
Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.
I’d like to look at the “state of affairs” in regards to physician leadership. One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.
ACDIS repeated the poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.
Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:
- “How have physicians reacted to your CDI program and query requests?” where only 40% reported a positive response from physicians
- “Are your physicians catching on to your CDI program? ” 3% yes, 74% yes and no, 23% no
- “Do you have any physicians who refuse to participate in your CDI program?” where 81% indicated anywhere from one to many physicians refuse
Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.
Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.
I think it is important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:
- Physician response rates
- Severity of illness (SOI)/risk of mortality (ROM) data
- Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)
I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.
As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.
Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.
If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.
I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.
I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.
I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.
Sometimes I wonder if just need to practice a little more persistence and a lot more patience.
By Heidi Hillstrom MS, MBA, RN, CCDS
After reading Penny Richards’ blog post, “Do you know who I am?” I wanted to expand on relationship building with physicians.
At my facility, we have a formal introduction process with all of our physicians and resident groups. During this time, we meet with new physicians to explain our CDI program. In addition, we regularly attend physician group meetings, staff meetings, physician quarterly meetings, etc.
Beyond that formal presentation, I find it is our informal interactions which have proved to be invaluable to our program.
I perform medical record reviews on the patient care floors, even if it is an electronic record review. This allows me to see and interact with many physicians on a daily basis. I have conversations with them and it’s not necessarily about documentation. Physicians are people too. Discussions do not always have to be about business or patient care or what is or is not in the medical record. Talk about sports, kids, or upcoming events. Build those bridges to enhance professional relationships.
“The difference between an interaction and a relationship is a matter of frequency. It is a product of quality, depth, and time you spend interacting with another person.” (Bradberry, Travis and Jean Graves. Emotional Intelligence. San Diego: Talent Smart, 2009.)
Relationship building has enhanced our CDI program. We have seen an increase in response rate, physician collaboration, and overall physician support.
By building bridges and relationships, a physician query becomes more than a nagging piece of paper or electronic note and the query’s author becomes more than a nag—he or she becomes a colleague. The achievement of this camaraderie enhances the ability to develop a documentation partnership between physician and CDI professional.
Penny Richards responds:
Thank you, Heidi, for sending in your comments on my original post.
I know I promised to give readers “five-minute speech” prep ideas, but I’m not a CDI and have little to offer by way of building relationships with the physician team. I can give you plenty of advice about breaking the ice and kicking off a conversation (I’m a talker and as a former newspaper reporter, have a lot of experience getting people to chat back to me).
When it comes to teaching points with the physician team, however, I bow to your expertise.
I hope ACDIS Blog readers will take a page from Heidi’s book and share suggestions and techniques. What have you done to train physicians and the clinical team on better CDI practices? What worked? What didn’t work?
Send me an email (email@example.com) and I’ll compile your comments. Yes, this is like an extension of the CDI Week Success Stories that many of you sent. It’s important to share successes. It’s also important to share the efforts that aren’t as successful. Maybe we can come up with a couple of Top 10 Lists… Successes and Flops. Sometimes you learn more by what doesn’t work than by what does!
Editor’s Note: Heidi Hillstrom is a CDI specialist at St. Luke’s Hospital in Duluth, MN, and the co-leader of the Minnesota ACDIS Chapter. Contact her at firstname.lastname@example.org.
Fluid in the interstitial spaces in the lung or fluid in the alveoli can be interpreted as pulmonary edema. With severe shortness of breath, it is likely acute pulmonary edema. Chronic pulmonary edema is usually a manifestation of end-stage heart failure. Patients with acute pulmonary edema may present with acute respiratory failure.
Cardiac causes of acute pulmonary edema include:
- Exacerbation of left ventricular heart failure with volume overload in end-stage renal disease (ESRD) patients who have chronic heart failure
- Acute MI whether from coronary occlusion or demand MI
- Accelerated (or malignant) hypertension including the severe hypertension that may occur with thyrotoxicosis, pheochromocytoma, carcinoid syncrome, eclampsia
- Tachyarrhythmia (AF with RVR, supraventricular tachycardia, ventricular tachycardia)
- Takotsubo syndrome (stress cardiomyopathy or apical ballooning syndrome)
Non-cardiac causes of acute pulmonary edema include:
- Pulmonary embolism (venus thrombi, fat or air embolism)
- Aspiration of gastric acid
- Sepsis (ARDS)
- Rapid decompression
- Volume overload in ESRD patients who do not have chronic heart failure
Was this an acute MI (including non-Q wave MI due to ventricular tachycardia, pulmonary embolism, or fat embolus? If so, document it as the cause of the pulmonary edema.
Was there chest trauma, rapid deceleration, sepsis, or ARDS? If so, document that as the cause of the pulmonary edema.
Did the patient aspirate fumes, vapors, gastric acid, or food? If so, document that as the cause of the pulmonary edema.
Is this volume overload related to renal failure with an otherwise stable heart? If so, document it as non-cardiac pulmonary edema.
If this is an ESRD patient with heart failure due to volume overload, state so. For example, write: “Noncompliant patient missed dialysis two days ago, admitted now in volume overload causing exacerbation of chronic diastolic heart failure.”
Editor’s Note: This excerpt was adapted from Documentation Strategies to Support Severity of Illness: Ensure an Accurate Professional Profile, second edition, written by ACDIS Advisory Board member Robert S. Gold, MD.
Scenario: You find yourself in the company of a physician you haven’t formally met, but for whom you have left queries (or may in the future). You’re in line behind the doc in the cafeteria or riding the elevator together, and you’re aware this is a great opportunity to say “Hello” and introduce yourself. What should you do?
I hope you put your hand out and start a conversation.
You don’t have to turn it into a big teaching moment. In fact, this might be the wrong moment to try that. Chances are the physician in front of you is lost in thought. Instead, make it a pleasant exchange.
“Hello, you’re Dr. Murphy, right? I’m Penny Richards, I work in the CDI department. I’ve sent you a few queries in the past. I just wanted to introduce myself and say ‘Hello’!”
Make eye contact. Smile. Don’t ask for anything business-related. Don’t ask the status of a pending query.
Keep this first face-to-face meeting upbeat and positive. If the physician transitions to a business conversation, then by all means, follow—but let him or her take the lead.
Pass your few moments together with light conversation. End your time together with something simple, such as “I’m glad I had a chance to meet you. I look forward to talking with you again.”
Remember: You never get a second chance to make a good first impression.
Ask yourself how you’d like to be greeted? With “Do you know who I am?” or with “Hello, you may not know me, I’m Penny Richards and I’m happy to meet you!”
This easy-in-easy-out greeting style is a great way to establish yourself with the clinical team as someone who is non-confrontational and open to having a conversation rather than an argument.
It’s also a great way to set yourself up to roll out your “Five-Minute Speech” at your next encounter. More on that in a future post.
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped breathing! And getting them to do what they should to care for the needs of their patients: Yes, I could really use a new central line for the 17 vasoactive infusions you’ve ordered!
I respect their level of education and their place on the food chain, but each physician operates on an individual plane of competency and personality for which I sometimes had to make adaptations in my approach.
When I worked in ICU, there isn’t much I wouldn’t do for a nice, polite doctor who showed respect to me and the patients. I knew how hard it is to become a doctor, and how really hard it is to become a good doctor, so I used to try to help the physicians by writing out a verbal order and having it ready for his or her signature. I would try to have all the necessary supplies ready ahead of time and if something additional was needed, I’d be the first to run to get whatever else was needed. Nice physicians got to sit in my space to write their progress notes. I even shared my Twizzlers.
Conversely, if you were a mean, crotchety doctor who didn’t show respect to nurses or patients, I wouldn’t be necessarily unkind but I certainly wouldn’t go out of my way to make your day better. I probably wouldn’t have your orders written and ready for your signature, I would show you where the supply closet was rather than get your materials ready for you, and I’d most likely not let you use my spot at the nurses’ station to write your notes. And no, no Twizzlers for you. Ever. Because you have to be a nice person, first and foremost.
In 2008 I left ICU and became a CDI specialist. Nobody knew what that meant, least of all the doctors. They just knew that I left on Friday wearing a white uniform and stethoscope and came to work on Monday in street clothes, pushing a computer on wheels.
When I was no longer running cardiac outputs or sending off specimens for C.difficile, they could no longer comprehend my new role against their earlier vision of who a nurse is and the role nurses play in patient care. I had to create a new identity and that meant redeveloping my existing relationships.