Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points.
Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term sustainability. The practice brief starts by highlighting that the foundation of physician engagement has unifying objectives as follows:
- Getting physicians involved early in the process
- Finding champions within the medical leadership
- Providing the necessary education to guide physicians asking, “what’s in it for me?”
- Sharing data-driven results and providing regular updates
Foundation of Physician Engagement: The “Missing Component”
While I wholeheartedly agree that these foundations of physician engagement are important, there are specific elements that are glaringly absent, despite being fundamental and requisite to sustainability and long-term success of documentation initiatives.
One fallacy permeating the clinical documentation improvement (CDI) profession, perpetuated by CDI consulting companies, is the notion that physician engagement can be measured and judged based upon the number of queries issued and responded to by each physician, with those figures then broken down further into a number and percentage of queries that increased a provider’s case-mix index and reimbursement, as well as impacted severity of illness (SOI) and/or risk of mortality (ROM).
I am not philosophically against this undertaking as an indirect measure of program penetration sparking physician interest and engagement. Just the same, we as a profession – both individually and collectively – must closely examine the foundation and structure of current CDI operational processes directly impacting physician engagement.
A pertinent question to ask is whether the level of physician engagement achieved in any CDI program initiative is satisfactory, and if so, how does one define satisfactory? Can physician engagement, even if one is convinced is sound, be improved somehow? In my mind “full engagement” of the physicians can definitely be expanded upon and improved if we acknowledge, realize, and integrate critical missing elements central to CDI processes. Let’s take a deep dive into these components and discuss how to best integrate them into current CDI processes.
Critical Overlooked Elements
Central to physician engagement in CDI is getting physicians involved early in the process, as well as finding champions within the medical leadership. The limiting factors here are assumptions that the present processes of CDI are a) structurally sound and executed in a meaningful fashion conducive to physician engagement and b) involving physician champions supporting the most ideal, meaningful messages to fellow physician colleagues regarding the merits of documentation.
Involving physicians early in the process creates a two-way dialogue on clinical documentation. Rather than providing physicians with a prepackaged approach to CDI that centers around the query process, involve physicians in an active discussion of clinical documentation with the intent of determining their challenges and issues regarding documentation. While, conceivably, some physicians will express an overall disdain for documentation, echoing usual points that it takes too much time, crowding out patient care, you will find valid, reasonable concerns from physicians related to documentation perils and potential knowledge deficits that can be addressed. This can in turn be incorporated into the development and implementation of their CDI programs.
I say this emphatically from first-hand experience, having completed a three-part series on Quantia MD geared towards physicians with content encompassing best principles and practices of documentation for physicians. Each five-minute recorded session generated hundreds of questions from participating physicians seeking clarification on specific patient documentation scenarios. Each of these questions entailed concepts and principles of documentation that the profession can and should be considering as an active part of their programs right from the start.
Physician engagement surely will have a strong tendency to be much more sustainable when we solicit real physician buy-in from the beginning, in direct contrast to assuming we can take a canned, narrowly structured approach to CDI and engage physicians from the get-go with taught buy-in tactical messages. Getting physicians involved early in the process entails providing an accurate message of the vision, goals, and objectives of any clinical documentation improvement initiative. A reasonable message is to outline what the medical record stands for and serves as, as a communication tool for all caregivers involved in the patient’s care.
William Osler, the father of modern medical resident training who established the first such program at John Hopkins Medical School, summed it up nicely when he stated that the record serves as a tool for observing, recording, tabulating, and communicating.
Communicating in today’s transformative healthcare delivery model extends well beyond describing a diagnosis, which is something we are fixated upon in present-day CDI programs, because it serves as the basis for measuring and evaluating physician engagement.
True Measure of Physician Engagement: Another Perspective!
Some in the healthcare industry promote and adhere to the notion that the valid and reliable measure of physician engagement consists of analyzing the monthly volume of transactional reactive queries for commonly queried diagnoses: the acuity of congestive heart failure, for example, or the degree of chronic renal failure, encephalopathy in the face of persistent versus transient mentation status, or acute respiratory failure in the face of acute respiratory compromise.
In my mind, the volume of queries should be consistently decreasing as physicians come to respect the value and worthiness of clear, accurate, and precise documentation. Now, how to fully engage physicians in learning about, becoming more knowledgeable in, and integrating and applying best practice standards of documentation into their regular practice of medicine? This is where the essentiality of employing and taking advantage of a physician advisor comes into play.
The practice brief pointed out the importance of employing a physician advisor as an effective strategy to engage physicians in becoming active participants in a clinical documentation improvement initiative. A true measure of physician engagement does not imply infrequent occurrences wherein a physician advisor must intervene, such as when the physician, initially fails to respond to a query. Instead, the level of physician engagement can be optimized by affording the opportunity for the physician advisor to contribute to the format, structure, and processes currently in place for most CDI programs.
Ultimate CDI engagement begins with unwavering engagement by the physician advisor in strategizing, planning, organizing, and building out present CDI processes. The brief points out that “physicians are indispensable to the CDI program and must be educated both on the fundamentals of a CDI program and the role they play to ensure the program’s success. There has to be significant program buy-in from the physician advisor, who will then encourage other physicians to be responsive to the program.”
I take a different outlook on securing physician buy-in from the physician advisor, seeing it as the qualifying factor to excel at engaging fellow physicians in participatory efforts at documentation improvement. Rather than educating the advisor on the merits of current CDI processes, allow him or her to observe the program in action, and to see first-hand the inner workings of the program, including current CDI daily operations, the query process, and the daily/weekly/monthly reports with KPI. Additionally, the physician advisor should observe the volume of denials originating with a query securing a diagnosis, with an eye on increasing reimbursement or improving SOI/ROM under the APR-DRG system.
DRG downcodes and clinical validation denials represent two things that clearly do not sit well with outside reviewers. Why accomplish all this in acclimating physician advisors to current CDI initiatives, goals, and objectives?
Simply put, the reason is to engage the physician advisor to arrive at his or her own conclusions as to the merits of program efforts. As the practice brief notes, physicians generally are very analytical and methodical, and will quickly conclude that to effectively engage others in any CDI initiative, present-day processes will require revamping.
The More Appropriate Approach to Physician Advisors: Driving Physician Engagement
The practice brief nicely points out that physician advisors are often actively involved in many different facets of supporting healthcare delivery, including safety, quality, case management, utilization review/utilization management, discharge planning, and denials and appeals. Fundamental to these efforts is documentation that best serves to communicate details of patient care.
Physician advisors can become engaged in documentation improvement initiatives if given the opportunity to drive improvement, identify efficiencies, and enhance the purpose and vision of such initiatives. Allow physician advisors to bring in a fresh perspective on the core principles and structural foundations of CDI, freeing them to expand our narrowly focused roles and objectives regarding such a small piece of documentation: diagnoses reporting. Expansion of our tightly defined CDI goals and objectives to include proactive efforts at enhancing accuracy, completeness, and effectiveness of documentation – from initial patient presentation to the hospital until the time of discharge – will unequivocally support the physician advisor’s efforts to engage physicians as true participants in documentation improvement. Physicians will arrive at their own conclusion that CDI efforts are genuinely targeted toward helping them improve the quality and completeness of their documentation, all in the name of communication of patient care.
Remember the Hippocratic Oath: “do no harm.” Communication of patient care supports and furthers the oath!