CDI Week 2021 Q&A: Serving your customers (physician engagement)

As part of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Rebecca Truett, RN, MSN, MBA, CCDS, CDI specialist at Novant Health in Winston Salem, North Carolina, answered these questions. She is a member of the ACDIS Leadership Council and of the 2021 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (criel@acdis.org).

Q: Can you describe the engagement and collaboration of the medical staff at your organization in CDI?

A: Physician engagement at Novant Health remains strong. We believe this directly results from leadership's recognition of our CDI program's positive impact on the organization and patient outcomes. Physician documentation is the only method available to accurately capture the actual severity of illness and risk of mortality of patients. Consequently, physicians recognize that CDI programs are by design focused on ensuring the integrity and reliability of clinical documentation to accurately reflect the quality of care provided.

Physician relationships are indispensable to the CDI program. Physician education must include CDI program fundamentals and the physician’s role to support the program's success. At Novant Health, there is significant buy-in from our physician advisor, who encourages other physicians to be responsive to the program. The focus on physician engagement and collaboration is vital because clinical documentation is the lifeline to coding, determining reimbursement, and reporting quality measures.

Regardless of specialty, physicians seek to diagnose and treat their patients accurately. Physicians collaborate with other physicians and ancillary staff to provide the best level of care. Finding ways to engage physicians and making them part of the CDI program will foster a team atmosphere and promote a successful CDI program.

Q: The percentage of respondents with “highly engaged” medical staff decreased from 20% to 14% year-over-year, according to CDI Week Industry Survey data. What do you think are the reasons physician engagement declined this year, when otherwise we’ve generally seen an increase year over year?

A: The year 2020 challenged all aspects of healthcare in this country. I am proud to say that Novant Health’s team members at every level worked together and gave of themselves in such a way that our organization is still growing and providing safe, quality care in all our communities. Medical staff understandably found themselves pulled in new and different directions during the COVID-19 pandemic.

As working conditions and processes changed rapidly, the need for in-depth specialty CDI reviews intensified. As CDI professionals shifted to accommodate changing needs, how we engaged and educated medical staff also changed. Virtual forums and one-on-one meetings with newsletters replaced hospital rounding. We found that the new formats allowed us more time with our physicians rather than less.

As we adjust to our “new normal,” we continue to see an increase in the volume of physician education requests. Our physicians see the advantages of increased collaboration for their practices and the organization, which further endorses the impact of the CDI team on clinical and financial outcomes.

Q: While only around 14% of respondents said their medical staff is "highly engaged" with CDI staff, another 51% said medical staff was "mostly engaged and motivated, with some exceptions." Collectively, some 65% of responses noted overall positive engagement. In fact, only 5% said medical staff was "mostly disengaged and unmotivated." Why do you think physician engagement is generally on the rise?

A: Physicians ultimately seek to diagnose and treat their patients to achieve positive outcomes. We recognize that a common barrier to physician engagement is related to not understanding the CDI program. Physicians may see CDI as part of the “bean counters” or “documentation police.” It is the responsibility of CDI leadership and professionals to educate providers and collaborate with them to reach shared goals.

CDI works with physicians and hospitals to promote positive outcomes by improving the quality of care and helping transform health systems to reduce quality care costs for all. CDI identifies four priorities:

1. Reduce harm in the delivery of care
2. Promote effective communication
3. Promote prevention and treatment of chronic disease
4. Make care affordable

We address these common priorities by using meaningful measures to help close care gaps, ensure appropriate diagnosis capture, provide accurate data to define at-risk and resource-intensive populations, and to allow for proper resource allocation. CDI professionals work daily to help physicians and healthcare facilities ensure diagnosis specificity and assist providers in translating the care provided into consistent language leading to accurate coding. CDI teams help providers recognize under-documented conditions and reduce clinical variation.

Finally, CDI programs are expanding to support clinical processes, and reduce adverse outcomes. As physicians understand that the role of the CDI professional is to assist their practice rather than hinder it, engagement and motivation naturally follow.

Q: Each year, we hear that physician engagement is a top concern or problem area for CDI programs. Why do you think CDI programs have such trouble in general engaging the medical staff? What have been your biggest challenges with gaining physician engagement? What have you done to address and improve this?

A: Despite data demonstrating the positive impact of CDI programs on clinical and financial outcomes, physician engagement is consistently in the top three listed challenges to any CDI program. I believe the adage “What the leader is interested in, everyone else is interested in.” Organizational leadership support is vital to a successful CDI program. Senior leadership that proactively addresses the need for excellent clinical documentation is the best tactic for ensuring physician engagement and motivation. A culture of professionalism, respect, and accountability with leadership support makes CDI a priority. When senior leadership understands the importance of CDI and its effect on hospital reimbursement, quality outcomes, public reporting, etc., they can defend CDI activities when physician questions occur.

In addition, key physician leaders can help CDI teams to identify obstacles, opportunities, and successes. Some focus points for engaging with physicians include:

• Identify opportunities for continued education on the CDI role
• Rehearse your interaction with a colleague. Organize your thoughts and be confident
• Don't limit your contacts to physicians, include allied health providers and nurses
• Give physicians feedback on CDI data.—they are interested in your effect on patient outcomes

The journey physicians take to motivation and engagement often travels a familiar path. Most begin with denial, sure that their documentation is good, and they do not need to change. Anger and resistance usually follow with physicians certain that “this is your problem, not my problem.” Then comes frustration. Often a physician leader has told the physician they must cooperate, leading to the attitude of “what's in this for me?” Eventually, most physicians reach acceptance. They have a better understanding of the CDI role and its effect on patient outcomes. Occasionally, the CDI team gains an advocate who shares their knowledge with colleagues and encourages additional engagement and motivation.

Q: Almost 13% of respondents do not have a physician advisor and do not plan to employ one in the future. What are the risks to CDI or to the organization as a whole of not having a physician advisor? Do you feel it is imperative to have a physician advisor? Why (or why not)?

A: Physicians synthesize information and apply it to patient care and outcomes but often struggle with translating that care into high-quality clinical documentation. Helping physicians understand how CDI can help with the struggle is where the physician advisor can help. Physician advisors are multifaceted individuals who are not only involved in CDI but may also be involved in patient quality and safety, utilization review, case management, denials and appeals, and compliance. Physician advisors work hard for quality patient care and support effective communication among physicians and staff members. The importance of their role in ensuring the effective and productive performance of a CDI program is critical. They play a significant role in educating the physicians about CDI activities, and they also act as a liaison with physicians who have poor query response rates. The physician advisor is crucial in educating the physicians on the importance of compliance to the various regulations that impact CDI and act as a mediator when there are conflicts internally among medical staff or other departments. Physician advisors become the mortar holding the bricks in the CDI platform.

Q: Do you provide formal education to your physicians? How is education content decided? How have your physician education/engagement models changed due to the pandemic?

A: Novant Health provides formal education to our physicians in the form of one-to-one meetings, group sessions, tip sheets, newsletters, and diagnosis specific education. Novant Health’s CDI education structure includes an education manager, a dedicated CDI educator, education focused auditors, EHR superusers, and service line specialists. Education content is decided with physician collaboration and driven by identified data trends.

In 2020, we expanded formats to include computer-based learning (CDL) and mobile applications. Physician education models changed during the pandemic. Our baseline knowledge of virtual meeting platforms enabled our team to rapidly transition to virtual forums versus hospital rounding.