Physician Engagement Includes Physician Documentation

EDITOR’S NOTE: Dr. Erica Remer reported this story live during a recent edition of Talk Ten Tuesdays. The following is an edited transcript of her reporting.

When I was a new physician advisor, the chief quality officer at my facility instructed me to not talk about money when discussing clinical documentation improvement (CDI). He said that doctors don’t care about money.

I was confused. I was a doctor, and I kind of cared about money. He corrected me, “doctors don’t care about the hospital’s money.”

That made no sense to me, either. It seemed to me like you would want your hospital to be successful. If money isn’t the impetus, what is? How do we engage providers and get them to change their documenting practices?

Do we have to persuade physicians to want to take excellent medical care of their patients? I should hope not. If your physicians are not inherently inclined to provide excellent medical care to their patients, they shouldn’t be on your medical staff.

Documenting the patient encounter is part of taking care of the patient. You don’t hire a house inspector to just inspect your house; a detailed report is implied and expected.

There are three fundamental reasons your providers should be invested in producing optimal documentation:

• It is in the patient’s best interests. The most important reason for documentation is for clinical communication. You are trying to convey information to the nurse, your colleague, your consultant, the therapist. You want them to know what you know, and what you are thinking. It often helps the clinician organize and solidify their thoughts for themselves. Being terse and cryptic serves no one.
• It is in the hospital’s best interests. A clinician is either employed by or has an affiliation with the hospital to which they are admitting patients. The provider should be supportive of their hospital’s success. There are quality measures that the hospital is being judged by, and rewarded or penalized for, in turn. If your hospital looks substandard on Hospital Compare, patients and payers may shun it. If they look bad in value-based purchasing, they may lose money. No margin, no mission.
• It is in the provider’s best interests. It is not just the hospital’s, but their quality measures are also derived from observed-to-expected risk-adjusted metrics. Their quality measures are available for review on Physician Compare, and may guide potential patients’ choice of provider. Their department or service line probably maintains statistics on their performance. Many hospitals have dashboards and privileges that incorporate some component of clinical documentation improvement (CDI) or quality metrics. There may even be money attached. If accountable care organizations (ACOs) don’t meet their goals, huge individual bonuses may be forfeited.

I think the key to engagement is ensuring that the provider understands the reason why they are being asked to alter their behavior. They need a motivating “ah-hah!” moment. I think it is easiest when you draw dots for them and give them the understanding and opportunity to connect the dots themselves.

I will share an exercise I find fruitful.

I ask providers to close their eyes and think of a patient with a principal diagnosis, which varies depending on the audience. I tell them to think about all the conditions the patient additionally had, which impacted the outcome. Then I have one share their vision aloud. It is either a benign or critical presentation. I then contrast it with the converse and inquire, “what is the difference between these two patients?” I let them come to the realization that it is the comorbidities that define the patient’s acuity, not the underlying principal diagnosis. “Walking pneumonia” versus septic shock due to aspiration pneumonia with acute hypoxic respiratory failure, culminating in death. Ah-hah!

I spend a lot of time trying to derive ways to educate providers and inspire them to document better. I’m pleased to announce that my new learning modules are now available for purchase. Feel free to check out my website, icd10md.com, for more information.

Programming Note: Listen to live reports from Dr. Erica Remer on Talk Ten Tuesdays, 10-10:30 a.m. EST.