• Getting Physicians Engaged in Clinical Documentation

    Aug 18, 2011

    By Shari Breuer and Venanzio Arquilla

    Now in its third year, the clinical documentation improvement program at UCLA Health System has successfully involved physicians by keeping the program's message on improving quality measures.

    The UCLA Health System in Los Angeles implemented a clinical documentation improvement (CDI) program in September 2008. Tom Rosenthal, MD, chief medical officer for the health system, was instrumental in developing the initial message to physicians regarding the importance of accurate, complete clinical documentation.

    "UCLA's physicians were not uninterested in the financial impact of accurate clinical documentation, but we surely got their attention around quality measures," says Rosenthal. "Each physician, as an individual or a group, has a reputation at stake in how his or her care is portrayed. Accurate mortality data are meaningful, and we would be foolhardy to ignore this part of the equation."

    UCLA Health System kept the message focused with its physicians during the initial program rollout and education. Now going into its third year, Rosenthal and other CDI program leaders are focused on maintaining the momentum they have had to date with their efforts.

    "To keep the program front and center, we are continually reminding our physicians of its purpose," he says. "As executive project sponsors, our CFO and I are equally interested in the quality and financial impact of accurate clinical documentation. There are many proposals for changing payment to reward quality, but the financial impact is not clear. The caveat is that there are dozens of quality measures at risk indirectly."

    The experience at UCLA Health System emphasizes the importance of keeping the message focused on the purpose of the initiative while continually monitoring the physicians' response to requests for greater specificity and clarification.

    Shari Breuer is a principal, The Claro Group, LLC, Chicago, and a member of HFMA's Minnesota Chapter (sbreuer@theclarogroup.com).

    Venanzio Arquilla is managing director, The Claro Group, LLC, and a member of HFMA's First Illinois Chapter (varquilla@theclarogroup.com).

    This article is excerpted from a longer, more detailed article by the authors, "Clinical Documentation Improvement: Focus on Quality," which appears in the August 2011 issue of hfm. (After Sept. 30, 2011, this issue of hfm will only be available to HFMA members.)