Improving Clinical Documentation By Engaging Physicians

Hospitals continue to focus on clinical documentation improvement (CDI) efforts to capture revenue that they may be missing today.  With the healthcare payment market continually in flux, not a dollar can slip through the cracks with the narrow margins that most hospitals are operating at. Having a robust CDI program is one way hospitals are attacking deficiencies in their revenue cycle by making sure their documentation is accurate and defensible, and supports their case for maximum reimbursement.

Many hospitals have tried different avenues to attack CDI, including engaging outside experts, developing internal teams to focus on CDI and many others. One avenue that hospitals should consider adding to their efforts is engaging physicians to provide accurate, specific and complete records in their patient care charts that are entered into the electronic medical record. As this article by Mike Miliard at Healthcare IT News reports:

“The challenge always has been documentation and the competing priorities for physicians,” said [Denise] Johnson, [vice president of HIM integrated services at nThrive]. “They have lots of individuals approaching them, around documentation and CDI. What we’re seeing too is they’re also being queried for information from the coding team still. Then there are the quality metrics that the quality group is focusing in on. And you’ve got case management also looking at them from a documentation standpoint. In some ways, it feels like they’re getting it from all sides.

“So I think one of the challenges organizations are facing today is really how to pull all of that together in a collaborative way in order to maintain that physician engagement without all of the alert and query fatigue that they experience,” she said.

So what are the keys to getting physicians on board with CDI, communicating its importance without badgering them into annoyance?

“One of the things we’ve found that has been really successful is physicians love data,” said Johnson. “One of the things we have seen really allowing us to engage with physicians has been giving them their data through our analytics.”

For example, “we have the ability to get detailed information for them around their queries, their query response rates – but also comparatively for them to their peer group,” she said. “We have the ability, as we’re rounding on the floors, to have those conversations – pulling up their data, showing them their trends for the last month, the types of queries they’ve had and identifying the ways in which we can help them so we don’t continue to query them. Because ultimately, that’s our goal.”

Another opportunity is to collaborate with the clinical informatics team to spotlight ways in which certain necessary documentation elements can be built into their EMR templates, said Johnson. “That’s another area we can explore to really engage the clinical team. Whether it’s a physician or a physician extender, we have seen that that’s been pretty successful in engaging them.”

Alerts – real-time notifications to either the clinician or the CDI team, depending on the technology, are another useful tool, when used judiciously, to help make sure “you’re getting it right the first time,” she said.

“And then the last piece I would highlight is around analytics – leveraging the technology to get robust data back to the physicians to track trends and then to collaborate on the back end, if we’re seeing denials, with the denials team so you can close that loop.”

Read the article at: How to improve clinical documentation

As the article states, a common roadblock to a successful CDI program is physician buy-in. As physicians already complain about burn-out from electronic documentation of their daily encounters, adding a CDI program to their plate may face resistance. One way healthcare providers can counter this is to arm their physicians and staff with the necessary tools to provide both excellent patient care and accurate and complete documentation of their encounters.  One way that hospitals can reduce the burden on clinicians is to eliminate redundant tasks in the EMR.  For example, natural language processing tools can help turn transcription data into notes that need to only be verified instead of typed in from scratch.  Additionally, automated data capture systems, such as iRISupply, can provide high quality data by integrating RFID data capture technology directly into your EMR, eliminating the need to have clinicians re-enter supply and implant information into the EMR during hectic procedures.