The MD Perspective: Improving Clinical Documentation
Many physicians can be convinced to participate in clinical documentation improvement efforts--particularly if hospitals convince physicians that there’s something in it for them. There is: Now that physician performance data is available online (for example, at http://www.leapfroggroup.org/ and http://www.heathgrades.com/), physicians are eager to find ways to improve their quality ratings. Since quality data is based on hospital records, physicians have a more compelling reason to document with the highest degree of accuracy.
Two physicians from the Medical University of South Carolina--Patrick Cawley, MD, executive medical director, and David Adams, MD, professor and section head of gastrointestinal and laparoscopic surgery--share their thoughts on how to get physicians more “invested” in clinical documentation efforts.
Why do hospitals continually have trouble getting physicians to adequately document the care they provide?
Adams: Among general surgeons, the problem is that there aren’t enough of them. There are only 1,000 general surgeons trained every year, and only 40 percent to 50 percent are staying in general surgery. Documentation is not a priority--they are just trying to triage human suffering as best as they can.
But that doesn’t mean we should ignore the problem. Surgeons can easily be made aware of how important it is to document, but they need help.
How much of this is an education issue, and how much is it a “time" issue?
Cawley: I don’t think time has anything to do with it. It’s an educational issue. And what’s in it for physicians is improved quality data. Their reimbursement isn’t affected, but their quality ratings are, especially as we report more and more of this information.
Where do clinical documentation improvement efforts go wrong with physicians?
Cawley: A lot of nonclinical people on the coding side see what’s in the ICD-9 codes and wonder why physicians don’t document that way. But, in reality, the clinical side and the coding side don’t match up.
A classic example is urosepsis, which to a physician means a patient who has a urinary tract infection who also is septic or likely to be septic. But the documentation guidelines don’t allow for this definition of urosepsis. In the guidelines, urosepsis means just a simple UTI. So the physician actually has to write UTI with sepsis. That doesn’t make any sense from a clinical standpoint.
Another example is around congestive heart failure (CHF). You have to document that a patient has CHF. But a physician may just write heart failure, systolic dysfunction, or diastolic dysfunction. In physician terms, those are all equivalent. But unless you write CHF, it is not correctly documented.
What are some other documentation pitfalls?
Cawley: A lot of facilities don’t engage their physicians in their clinical documentation improvement efforts. When you start showing the quality data to physicians, and they don’t look good because they didn’t document properly, they will change. There has to be a feedback loop. But a lot of hospitals don’t do that at all. Or, if they do it, they just have one or two teaching sessions and think the physicians will pick up better documentation habits. But you need a much more robust feedback circle if you want physicians to change.
Clinical documentation improvement is not something you do once and then four or five years later when the hospital’s reimbursement is affected. You have to have a continuous process that gives feedback to physicians. You have to inform physicians of changes to coding practices and educate the new physicians in the hospital.
What kind of quality data do you share with physicians at your hospital?
Cawley: We show physicians their mortality data, for example. We show them that by better documenting some of the complications that occurred with their patients, they can improve their mortality data a certain percentage. This works best when the department chair or medical officer is there with someone from clinical documentation improvement to share the data with the physician.
Any special advice for teaching hospitals that work with residents?
Cawley: If there is any error that is made with clinical documentation and residents, it is that there is too much of a reliance on residents for documentation. A hospital needs to work at the attending level to fix things. If an attending tells a resident to document a certain way on rounds, it will stick with the resident better.
What advice would you give to nurses and other hospital staff who work with physicians to improve documentation?
Adams: It’s like that real estate saying--location, location, location. Except, in this case, it’s repetition, repetition, repetition. This means making time to round with the physicians and providing written suggestions on improving documentation whenever possible. Give us clear examples of what’s wrong with the documentation in the record and what kind of documentation you need, and you’re more likely to get us to change.