Working with Physicians to Improve Documentation

April 6, 2017 8:57 am

Revenue cycle leaders may need to address physician concerns before expecting them to embrace new initiatives, says Leigh Williams, University of Virginia Health System.

While health systems wait to learn what changes will be forthcoming from the new administration in Washington, one thing is certain: “It is going to be important that we embrace working together with our clinicians to get our health systems through what could be more rapid change than we have been anticipating,” says Leigh Williams, administrator of business systems at the University of Virginia Health System (UVA Health System).

Now more than ever, accurate and complete documentation is needed to support care coordination, quality measurement, and payment. Success hinges on physicians who can document properly and value good documentation for their own reasons.

Nagging physicians to improve documentation is not a strategy; it is just nagging. Revenue cycle leaders must understand how physicians think and what motivates them to focus carefully on documentation, Williams says. The nature of physicians’ responsibilities to patients requires that they have confidence in their decision-making and ability to prioritize.

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“You need to be mindful that physicians are people who have been trained to be independent thinkers who will trust their own interpretation of things above other opinions,” Williams says. “If you have five doctors, you may have to explain something five times—not because they are obtuse and want to take a lot of time, but simply because of how they are trained to trust themselves in medical school.”

Preparing To Be Successful

Whether an organization is launching a new initiative that requires physician buy in or documentation simply needs to be improved, mutual respect is the foundation of success.

“The whole idea of the annoyed doctor who does not have time for these things and is too smart to understand anything is just distasteful,” Williams says. “These conversations require me being an expert in my own field and meeting them as experts in their field.”

Be an expert. “If you are disorganized, you cannot explain what you are trying to do, you do not fully understand documentation, and you are not able to relate it to physicians’ work. They do not have much time for that,” she says.

Do your homework. To prepare for a meeting with a specific group of physicians, review their website, access other available materials, or talk with colleagues who are familiar with those physicians. Think about their perspectives. Will their specialties be highly affected by the new initiative—or will the effect be minor?

Be clear about the objectives for each meeting, rather than delivering the same presentation to every group of physicians.

Courtesy counts. Be mindful of physicians’ time and offer convenience. “If the meeting needs to be at 7 a.m., it needs to be at 7 a.m.; if they are delegating to someone, you go to that someone else,” Williams says. “You take what they are able to give you. Once they begin to trust you, because you have proven that you can make the changes that you said you were going to make, and you make good use of their time, they will give you more time.”

Listen first. “You cannot walk in with everything figured out and tell them how it is going to be,” Williams says. “It takes a lot of listening to get to where they are.”

Do physicians make gruff comments about continuing changes from CMS? Are they sick of technology? Are they cynical because they feel past promises have not been fulfilled? Or are they supportive but unsure of what to do? A good working relationship means that revenue cycle leaders understand physicians’ perspectives and priorities, which may mean addressing their concerns before expecting them to embrace new initiatives.

“You can’t just dismiss something they say,” Williams says. “In a few instances, we have had to address some things first to free their time to work on our priorities.”

Use the best communicators. When it comes to documentation details, identify the staff members who have the best interpersonal skills to work with physicians—and prepare them to deliver specific information.

“You cannot just tell the physicians that their documentation is vague—you need to help them understand what it is that you need,” Williams says. “Having people with a clinical background or with deep knowledge of the language that needs to be in the chart is important.”

Be flexible when possible. Sometimes clinicians have their own ideas about how certain things should be described in the patient charts. If they all agree to use similar language, clinical documentation improvement staff and coders can be coached on how to interpret the documentation for proper coding instead of insisting physicians conform to coders’ preferences.

See related sidebar: Finding Common Ground on Physician Documentation

Seek guidance. If possible, partner with key leaders. “I sometimes have open dialogues with physician leaders within different specialties,” Williams says. “Whatever your reason is for being in the room with them—‘We really have got to comply with this rule, we are losing money here, or we are at risk for these quality measures’—you can be open and frank and center the discussion around finding solutions that work for everyone.”

Measuring Progress

Documentation improvement should be monitored both quantitatively and qualitatively. Identify metrics and be clear on the initiative’s goals such as improved quality scores or reduced rate of claims rejected for unspecified codes. Goals should include metrics that reflect physician priorities.

Williams recalls one project that focused on length of stay and denials, which were key to the health system but not top of mind for physicians. “The providers were primarily focused on their RVUs,” she says, referring to the relative value units used to measure physician productivity. “We added metrics related to collection ratios and dollars per RVU. Those resonated with the physicians because they were tied to their existing incentive structure.”

Determine the timeframe for evaluating progress. Set an expectation for when progress should be evident. Insurance claims may take many months to be processed, so metrics such as denial rates or increased revenue from better documentation will not be seen for quite some time.

Look for the unmeasurable. Williams could tell that her team’s efforts to engage physicians were working when physician leaders started reaching out to her for help. “When department chairs called to ask for my help or saying, ‘I want to use the same approach we used on that other project,’ I knew we were gaining traction,” she says.

Working Together

Accurate documentation in patient charts is essential for many revenue cycle initiatives. Getting high-quality documentation requires understanding physicians’ priorities, their thinking styles, and the time pressures they work under. A key way to motivate physicians to improve documentation is to relate it to patient outcomes.

Interviewed for this article:

Leigh Williams is administrator, business systems, University of Virginia Health System, Charlottesville, Va..


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