In February 2015, the American Hospital Association (AHA), in conjunction with Executive Health Resources, launched its inaugural clinical documentation improvement (CDI) survey, “Emerging Trends for Clinical Documentation Improvement in 2015,” to help determine the main barriers to CDI success. Many powerful insights related to physician engagement in CDI programs were revealed by the survey’s participants, which included more than 1,000 CDI, coding, health information management (HIM), and other professionals in CDI programs across the United States.

About the Survey

The survey was promoted nationwide and the results reflect a balanced representation across the country (plus Washington, D.C. and Puerto Rico). The provider landscape represented was diverse and included small hospitals of under 200 beds (27.3 percent), midsize hospitals of 200-plus beds (33.7 percent), and multi-hospital systems (28.9 percent).

Most programs (87.9 percent) represented in the survey results either are in a growth or mature stage of their CDI program, well past the inception phase.

Most respondents also indicated that their programs include dedicated CDI resources covering review of most Medicare cases, with some focus on quality measures and metrics, such as severity of illness (SOI)/risk of mortality (ROM) and various levels of physician education. Technology platforms are in place for 61.1 percent of the programs and influence CDI case selection at 16.7 percent of respondent hospitals. 

The query response rate for these organizations is above 80 percent, at 47.7 percent of these programs. Query resolution occurring before discharge happens 57.4 percent of the time, which means these queries are completed concurrently – while the patient is still in the hospital.

CDI professionals were the primary respondents in the survey, making up 71 percent of the total. Other groups included coding (7 percent), HIM (8 percent), physicians (2 percent), and other professionals (11 percent).

Barriers to Success

If you had to guess the percentage of CDI programs that currently have physicians who could improve their documentation practices, what would you guess? Twenty-five percent? Forty percent? Sixty percent? 

The survey results indicate that 98.5 percent of CDI programs have physicians who could improve their documentation practices. This overwhelming issue is critical to hospitals, since active participation from treating physicians is the No. 1 factor that will lead to a successful CDI program (with 78.4 percent of respondents in agreement). 

There could be many reasons for this – lack of hospital leadership, lack of ongoing physician training, collaboration issues, just to name a few – but it’s clear that there is no shortage of roadblocks to proper CDI. Still, a resounding 95 percent of hospital respondents noted that engaging physicians is the biggest issue they face. The primary barrier prohibiting physicians from being effectively engaged in CDI is a lack of understanding of the importance of strong documentation (66.5 percent), with lack of time (47.5 percent) and lack of interest (38 percent), coming in second and third, respectively.

A small group of outliers (5 percent) indicated that physicians are all highly engaged at their hospitals, with no barriers preventing engagement in CDI.

Another challenge revealed in the survey findings relates to the scope that current CDI programs have on the greater patient population. Typically, 65.5 percent of the time, these resource-constrained programs target cases based on the payer type, leaving most hospitals (82.8 percent) unable to ensure that all complex cases go through CDI review.

Commercial health plan cases are vastly underrepresented in CDI programs (24.6 percent), while the primary focus remains on Medicare fee-for-service (58.5 percent), Medicare Advantage cases (46.1 percent), and Medicaid cases (25.8 percent). In addition, 37.5 percent of respondents indicated that their CDI program is able to target equally across payer types.

Technology’s Influence

There’s no shortage of opinions on the best way to improve physician documentation in support of CDI. The survey indicated that only 13.5 percent of respondents view a strong technology platform as the most important factor that will lead to a successful CDI program. Not surprisingly, CDI professionals view technology as less of a barrier in preventing proper documentation than physicians do.

The advent of the electronic medical record (EMR) has done much to organize and stratify clinical information, but doesn’t always yield an inherent improvement of documentation standards. Some physicians feel that EMRs turn a patient encounter into an exercise in physician data entry and can limit their ability to expand on their comments within the record.

Often there are patient details that are crucial to accurately representing the complexity of a case and delivering quality care, but they don’t neatly fit into one of the EMR’s fields (e.g., templates and checkboxes). This design flaw in EMRs can unintentionally omit this crucial information from being documented in the patient’s medical record, and instead the information remains noted only in the physician’s mind. Add to this the fact that 51 percent of physician advisors (or “physician champions,” as they can also be called) have had very little or no training on CDI and ICD-9/ICD-10, and the issue becomes even more critical.

Advancements in technology that leverage natural language processing and computer-assisted coding can be an effective solution to address the documentation gaps prevalent in EMR systems.

In addition to the 61.1 percent of CDI programs detailed in the survey that have a technology platform in place, another 11 percent of respondents replied that they have plans to implement technology.

More Time and Better Timing 

Delivery method makes a substantial difference in delineating the most effective educational approach, with 84.3 percent of respondents saying that one-on-one, case-by-case conversations among physicians is critical to CDI success. Real-time, patient-specific conversations are the most effective education strategy to make physicians aware of how to improve documentation, but unfortunately, this can also be time-consuming and resource-intensive for hospitals.

More than 89 percent of those participating in the survey reported that their CDI programs lack a full-time physician resource. With responsibilities spanning from utilization review to length of stay to readmissions to medical necessity determinations – and the list goes on – physician advisors/champions have limited time to dedicate to CDI, let alone to holding case-specific educational conversations with peers. Only 18.5 percent of the time can physician advisors/champions spend more than 10 hours a week focused on CDI, with only 5 percent of physicians dedicated solely to supporting CDI. 

Without a dedicated physician advisor/champion, the burden of engaging treating physicians falls on others within the medical staff and the CDI team members. 

Not only is a lack of time a factor with physicians, but timeliness is important as well. Being able to resolve queries while the patient is still in the hospital bed and the physician’s observations are fresh can be critical to the success of CDI – but only 2.7 percent of queries are addressed in less than 24 hours. 

Best Practices 

Despite where your hospital’s program is on the CDI continuum, promoting physician-to-physician interaction is critical to the success of the program. A physician-to-physician interaction model can have an impact in many areas: elevating physician engagement and documentation quality, implementing case-specific education from peers, managing queries real-time (pre-discharge), addressing CDI resource constraints, and augmenting physician resources with limited training. 

Introducing physician education to promote engagement in your CDI program may present a bumpy road, but here are a few tips on where to start that could help improve the ride:

  • Educate physicians in the way it works – not the way you’ve always done it. Real-time, patient specific conversations are the most effective education strategy to make physicians aware of how to improve documentation (with 84.3 percent of survey participants agreeing), and some of the most prevalent approaches hospitals use to educate physicians were deemed ineffective (i.e. Web-based training, emails, lectures/seminars, posters/flyers).
  • Acknowledge the limited time that physicians can allocate to CDI. Conflicting priorities and limited bandwidth leave hospitals seeking outside physician expertise to augment CDI program effectiveness. (Eighty-three percentof physician advisors/champions spend 0-10 hours a week supporting CDI.)
  • Make sure physicians know there’s room for improvement across the board. Despite the expertise of your medical staff or where you’re at in your the CDI program, improvement opportunities are a universal theme, with 98.5 percentof programs having physicians who could improve documentation practices.

The role of an effective, knowledgable physician advisor in CDI is the cornerstone of any solidly built program. This individual helps to ensure that documentation can be supportive, as Recovery Auditor (RAC), Medicare Administrative Contractor (MAC), and commercial payer DRG denials are increasing, with the reason of “not clinically supported” used more now than previously noted. Just because the physician writes a diagnosis does not mean that it is supported in the medical record.

The physician advisor can also elevate documentation practices that mitigate vague, incomplete, and conflicting information coming from staffers ranging from CDI professionals to physicians to coders, and he or she can help ensure that queries are more effectively and expeditiously answered as peer-to-peer engagement bridges the gap in documentation interpretation.

Furthermore, the physician advisor serves as a clinical advisor to clinical documentation specialists and coders, helping perform chart review on requested cases from the CDI team, aiding in ongoing physician education, and truly becoming a champion in supporting the CDI program.

A physician-to-physician approach can help produce improved documentation, which can lead to increased accuracy and the ability to track DRG and quality metrics (SOI/ROM). In addition, this approach can help reduce the time spent by both CDI professionals and physicians on query resolution. Furthermore, treating physicians will learn from physician-to-physician discussions and improve their documentation practices. In the end, thorough documentation provides instant defensibility if auditors come knocking at the door. 

About the Author

Dr. Ralph Wuebker serves as chief medical officer of Executive Health Resources (EHR). In this role, Dr. Wuebker provides clinical leadership within EHR and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees EHR’s Audit, Compliance and Education (ACE) physician team, which is focused on providing on-site education for physicians, case managers, and hospital administrative personnel and on helping hospitals identify potential compliance vulnerabilities through ongoing internal audit.

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