Top 5 reasons your Physicians are not engaged in your Clinical Documentation Improvement Program
Clinical Documentation Improvement (CDI) initiatives have become a thriving and indispensable industry over the past decade. The value proposition for CDI is obvious, well, at least to those who are either in the business, or those that have some accountability attached to a well-functioning, effective, and compliant program. For the most part, this group historically did not include the mass market of practicing physicians who these programs are aimed at assisting in order to achieve optimal and accurate documentation, which, in turn, results in accurate coding to support quality, cost, and value measures.
This is indeed troublesome and through years of experience in the CDI industry, it has been proven that this group of "disengaged" physicians is not unique to one state, type of hospital, or even specialty group. This is, in fact, a universal problem. Now, I know that physicians in certain specialties are known to play very well in the sandbox with the CDI function more than others, but I think it’s safe for me to go ahead and make a blanket statement that the lack of physician engagement is an issue across all specialties.
At a time when hospital-physician alignment is so crucial to the long-term success of an organization’s goal of demonstrating value within the patient population being treated, why are efforts to ensure physician engagement not an area of focus for CDI?? Do we not want to "stir the waters" with our high volume and high revenue docs? I can tell you that for the longest time, this was and probably still remains an issue. Healthcare administrators are concerned about the dreaded words from the Orthopaedic Surgeon saying: "I will just take my business elsewhere!"
Interestingly enough, "elsewhere" is no longer a safe haven for the disengaged physician. Show me a hospital that doesn’t focus on initiatives that demonstrate value to patients (including CDI) and I will probably say that that hospital possibly exists outside the borders of the U.S., or if it doesn’t, then it is a dying breed for sure.
With regards to CDI, once again, I don’t believe much emphasis has been placed in the industry on trying to determine why our physicians are not somewhat, if not fully engaged. Great software, productivity measures, and workflow recommendations are rife in the industry, but when organizations do not invest in the research and tools to equip physicians to support the program, I cannot help but wonder if we do it all to check off the "CDI box" at many organizations.
The efficiency and effectiveness of a CDI program relies heavily on the active buy-in and participation from the physicians, and if no efforts are being made to engage the docs, then your true potential as a CDI program will never be realized. There, I said it!
So what are the main reasons that your docs are not engaged in the CDI program? Well, there are probably far too many to mention here based on the different variables that will impact engagement, but here are the top five that I have come across in the industry. These five were chosen because they are issues that we can actually take action on and make right on our journey to increased physician engagement with the CDI program. Note that they are in no particular order.
1. LACK OF ATTENTION FROM ADMINISTRATION
Why should the physicians be engaged in an initiative when administration has not been explicitly clear as to what the expectations are for physicians? Unfortunately, the extent of C- Suite involvement in many CDI programs across the country has been to the extent that they have "budgeted" for a program to exist at their organization. I have seen both ends of the spectrum though – on one end, a CFO gets on the phone with poor performing physicians to get them to education sessions, versus the other end where the CFO would rather dissociate themselves from an initiative that appears to be a thorn in the physician’s side. It starts at the top, and yes, it rolls downhill.
2. Not understanding the "Why?" of CDI
This has been one of the biggest challenges in the past. Physicians may perceive that CDI is just about the hospital’s "facility fee" and does not impact their pocketbook. With the introduction of physician quality scores and the associated impact on ProFees, CDI will start hitting closer to home as documentation quality impacts quality score risk adjustment. This is still an issue of concern and a physician’s intense clinical schedule leaves very little time to devote to understanding the value prop of CDI.
3. Performance measurements and metrics
I just got back from a conference where "query response rates" were still being used to measure a physician’s performance and contribution to the CDI program. Wait, so what comes across as an administrative duty to physicians (answering the query) is being used to determine the physician’s active contribution to the program? Great – let me answer all the queries for the sake of answering them so I look good on paper, and in the process, leave no lasting positive effects on my documentation habits. Ever wonder why we send the same queries to the same physicians on the same diagnoses month after month? Are physicians who rarely get queried the best documenters or are they the ones who are less responsive or intimidating to query (e.g., a well-known Neurosurgeon)? Physicians are more engaged when the metrics are pertinent, specific, and a true reflection of an initiative striving to assist them by making them better at something.
4. Insufficient tools to make this an easier process
A physician who understands the "Why?" and wants to do the right thing will very easily get frustrated if the tools don’t exist to make this an efficient process for them. This may range from optimizing the EMR, to supporting the program expectations, to providing the educational tools that are convenient to their schedules. I have been a firm believer that until "CDI" is taught in medical schools (and that does not seem to be on the horizon), a physician’s optimal performance will never be dependent on a physician becoming a CDI subject-matter expert. Instead, we need to provide for them the quickest means from point A (current documentation habits) to point B (providing accurate, code-able documentation the first time around).
5. Poor reporting and feedback
Here’s an old adage you’ve probably heard a million times before: "If you don’t measure it, you can’t manage it," but more importantly for physicians – they can’t "improve" it! Once you choose the metrics for performance measures, share them with your physicians. More importantly, share them alongside their colleague’s performance scores on a regular basis. Physicians are competitive, so they will make an earnest effort to improve their documentation habits when their performance is based on actual data that compares them to their peers (assuming the data is credible). I believe this is where CDI has been lacking for so many years. Don’t forget that sharing query response rates is not good enough because a high performing physician should really be seeing less queries if s/he has been leveraging what your program has to offer in the long run.
As mentioned earlier, there are probably many more reasons we can jot down, but here are five that we can effect change on and possibly assist physicians in achieving optimal engagement, and more importantly, performance in your CDI program.