Clinical Documentation Matters

I once had the pleasure of providing basic coding and clinical documentation training to a group of anesthesiologists.  The group of about 20 physicians were, to my pleasant surprise, quite engaged in the topic.  Although the medical center was a teaching hospital, they had no anesthesiology residents, so all of the attendees were attendings.  And, unlike many anesthesiology departments today, most of the anesthesiologists in this hospital were dedicated almost 100 percent to sugical anesthesia practice - not alot of pain management activity in this particular department. This turned out to be a good thing - since it's the documentation - or lack of documentation by anesthesiologists just prior to, during and after surgery that tends to be a challenge for clinical documentation professionals.

At one of my former companies, we had an HR director who noticed that some of our employees suffered from what she called the “what can you do for me now?" syndrome. The syndrome, for which I do not believe an ICD-9-CM (or ICD-10) code exists, occurs when managers lavish rewards on employees - both tangible and intangible - and, is particularly likely to occur when the rewards and constant positive feedback are not tempered with critical feedback or consequences.  I believe the syndrome may be more common in firms that depend on the expertise of technicians, like coding, CDI, or financial reimbursement experts.  Managers fear the loss of an expert and may overcompensate for that fear through rewards and constant positive feedback. The psychological impact, through no fault of the employee, is the creation of an expectation of more.  Like Pavlov's dog, we become conditioned to expect More recognition.  More rewards. More. More. More.  So, we needed to recognize that it was our managers (and our overall corporate approach in some cases) who needed to change their own behaviors in order to create a more suitable atmosphere for everyone...

Earlier today, I received an email from a potential purchaser of the Basic Coding and CDI Training for Physicians online training program…..the writer was from a small hospital and his question was whether the training addressed the “what’s in it for me?” for physicians.  This got me to thinking about the "what can you do for me now?" syndrome and whether there might be a relationship between the two.  Here's what I think.....in many hospitals physicians have the perception that the hospital "owes them" - after all, if it wasn't for the physician admitting patients to the hospital (they think), where would the hospital be?  And, over the years, I have watched this scene play out in hospitals. In most cases, when I traced the behavior through interviews with administrators, managers, and review of policy.....physicians' perceptions were either created or strengthed by the actions, philosophy, and policies of the hospital.  There are some healthcare systems and AMCs where expectations of attendings are managed from day one - in other words, the physicians understand that in return for continued admissions priviledges, they have certain responsibilities.  And, one of these responsibilities is providing high quality clinical documentation in patient records....

A few years ago, I had the pleasure of speaking as part of a panel on clinical documentation at the AHIMA annual meeting which was held in Washington DC.  The meeting was held concurrently with the International Federation of Record Organizations (IFRO).  The other members of the panel were from Israel, Australia, Germany and Ireland.  I must admit, I was concerned about how much we would have in common and how well our presentations would flow together.....To my surprise and relief, each of the presentations could have been cut from the same cloth!  The Israeli presenter described lack of detail in operative reports resulting in incorrect coding.  The Australian presenter talked about physicians ordering meds and tests without documenting the patient's diagnosis. There was a common CDI bond among us that was apparent throughout the presentation....fittingly, as we begin 2010, one of my intentions involves making CDI a global discussion through resources like this blog. Why is this important?  Because some of the best and most creative results come from diverse input...with feedback from readers in all countries, states, and types of hospitals and healthcare systems, together we can find some creative solutions to persistent CDI challenges.  In that spirit, I would like to dedicate the month of January to blogging about those persistent CDI challenges.  So, please provide your feedback on the blog page directly, or if you'd rather, email me directly.  We'll use January to outline the challenges and then, address specific solutions as the months progress......Thanks to everyone for your contributions!

Every once in a while I go back to books I read for my Medical Anthropology classes, especially the ones that described the cultural impact of medical school education on physicians to help me understand physicians as their own cultural group, which they are.  In From Doctor to Healer, Robbie Davis-Floyd interviewed many physicians about their medical school experiences.  In one chapter, she pulls together quotes from some of the interviewees who she considers to be "Humanistic Physicians"....I have found that reading these before a training session has helped me to see the bigger picture and try to understand where the physicians are coming from, since I was not trained as a physician myself.....here are a few excerpts.  If you have a weak stomach, you may not want to read the second interview statement.  (1)  From Paulanne Balch, MD:  Medical school is so sterile and abstracted from the person....you begin by learning about a disassembled set of organ systems.  That's about the most integrated it gets.  You learn about the digestive system, the circulatory system, the nervous system.  You learn about...how to break down information a patient might give you as to which body system is involved.  Then you develop a treatment program based on the results of your diagnosis.  Notice I have not spoken a word about the person.  And, the crisis, if it occurs for you, is when you sit down with a person to solve a problem they have and you don't have any tools from your training to recognize the fullness of a human being (page 60), and (2) Terry Tyer, MD:  The first week of medical school, we were required to dissect a fetus...our group had a full term baby, which had been stillborn.  The very first thing we were to do was take a meat cleaver and do a saggital section through the head of the fetus....out of my class of 85 students, 6 did not return the next day. (Page 75)"

While preparing for my move to Southern California in a week, I came across a series of Clinician-Patient Communication CME courses offered by UCSD School of Medicine. Included in the course description was the following statement,  "Overview: Improved diagnostic accuracy, greater involvement of the patient in decision making and increased likelihood of adherence to therapeutic regimens are all outcomes of using effective communication strategies."  And, the hook for the physicians was, "Additional benefits are an increase in patient and clinician satisfaction and a reduced likelihood of malpractice litigation."  ACGME is also requring similar types of courses for resident education.  And, let's face it, many physicians can benefit from training in this area.  There are tons of books written about improving physician-patient communications - I even wrote one! There's even a theory by medical anthroplogist Robbie Davis-Flloyd that she describes in her book, From Doctor to Healer, where she details the transformative journey from technocratic medicine (where most physicians are "stuck" because of how they are trained) to humanistic medicine and finally, if ever, to holistic medicine.  In the book, she emphasizes the lack of communication skills that physicians are taught during medical school.  Harvard CMEs Oline offers a series of Lifetyle Medicine courses where the focus is on "coaching" patients. So, I got to thinking, if the clinician-patient communication topic is a popular one that physicians will attend - or better yet, pay to attend, why not infuse it with CDI propaganda?  Afterall, one of the things I teach in my healthcare consumer courses is that it's our responsibility as patients to communicate reliable information to our physicians - and, the quality of our communications determines the quality of clincial documentation and hence, the quality of care we receive. The pendulum swings in both directions......linking communication with documentation seems like a natural progression for physician CMEs...

The "Feedback is the breakfast of champions" blog entry received a lot of feedback!  I wanted to highlight one question, in particular, that came to me via email:  "I wonder how large a role you believe physician liaisons should play in providing feedback to their colleagues when it comes to documentation improvement. My guess is it would be too expensive to use a physician to act in this capacity full time but perhaps  physicians could be employed in some capacity in the process? "  There are indeed some programs where the CDI function reports to a physician who functions in an advisory capacity - providing feedback to physicians who have documentation deficiencies.  But even in those programs, the managing physician can not possibly provide all feedback - so often, physician manager provides feedback to members of the medical staff who provide the biggest documentation challenges.  In my experience, there is one big "pro" and one big "con" to employing physician CDI advisors.  First, the pro....research (and practical experience!) has shown that we learn best when instruction (or feedback) is provided by a peer.  In fact, the "P" in the CAMP Method actually represents the phrase "peer learning".  For effective physician feedback, it is important to understand exactly who they see as a peer - and, that may not include a physician who is the CDI manager! The two best models that I have seen (and helped to implement) for CDI peer feedback included a hospitalist model and a department CDI meeting model.  In the hospitalist model, the CDI expert team trained 6 hospitalists in intensive clinical documentation methodologies.  In addition to provding better documentation for the patients they treated, the hospitalists were also responsible for providing feedback to physicians who had been identified as poor documenters by the CDI specialist team.  In the department meeting model, implemented by an AMC, departments met monthly over lunch (provided by the system) to discuss records with documentation deficiencies.  The AMC's CDI team attended the meetings, but the real communication was among the physicians themselves.  They looked at each other's records, gave opinions, asked the CDI team questions - this is a rare occurrence - but produces the best outcomes.  Of course, it only happened because of significant efforts on the part of the CEO (a physician), the CFO and the system's overall philosophy about the importance of high qualty clinical documentation.  Now for the "con"....I have also seen more than one hospital hire a physician to manage the CDI program, give them unbridled authority over the process, and end up in a lot of hot water.  Lack of education and direction, little or no feedback, and providing the wrong types of incentives (i.e. bonuses for queries that produce an economic impact...!)  all contribute to CDI programs that are compliance challenged.  I do believe that the right amount and type of education can turn what could be a disastrous physician CDI management venture into a shining star - I describe this in Education Will Set You Free (A downloadable White Paper)....see what you think....