February 13, 2018

Three Key Initiatives for Improving Physician Education for CDI

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If physician training and education on clinical documentation is not done correctly, you might as well not do it at all

It is common knowledge that the reason clinical documentation integrity (CDI) programs exist is to bridge the gap between the language physicians speak and what can be accurately captured and coded to represent true patient severity that is communicated to the outside world.

In addition, after many years in the industry, it is apparent that CDI really goes beyond that alone, especially when you look at other initiatives that rely upon correct and compliant documentation (such as the two-midnight rule, meeting medical necessity, avoiding denials, and so forth).

It stands to reason, then, that physician education should be an integral component of all documentation efforts at your facility. That is, of course, unless you don’t prioritize improving the documentation culture at your organization. I will discuss a few modalities and approaches to documentation education for physicians, along with their challenges, and will end with what I have found to work best with physicians.


Face-To-Face, Peer-To-Peer Education

It is widely believed that physicians will only learn from other physicians, and that bringing in a subject-matter expert will probably not be well received if that individual is not a clinician themselves. I personally struggle with that mentality, as I would rather take advice from a subject-matter expert on a topic over them simply being a clinician, but nevertheless, that seems to be the belief pattern of many physicians and healthcare leaders. I have, in my past life, had the opportunity to provide face-to-face, peer-to-peer education on clinical documentation to clinicians. Here are some of the challenges that I faced:

  • Scheduling and Attendance: Competition for a physician’s time is intense, and getting physicians to attend a preplanned session on a topic most likely will not be a high priority for them – this makes things difficult, to say the least. Attendance was a universal problem in my past experiences, regardless of specialty, size of facility, or leadership.

  • Incentives: Many physicians did not feel sufficiently incentivized to attend these education sessions, very frequently going back to the “what’s in it for me?” question. Sometimes breakfast, dinner, or even wine may have lured them in, but I would argue that if that’s what it takes to get our docs interested in documentation education, then we are starting off on the wrong foot.

  • Behavioral Change: For those docs who did attend the sessions, many of them were curious about the implications of documentation habits that did not fully capture true patient severity. Physicians loved seeing data that demonstrated cause-and-effect scenarios. The challenge was that these “engaged” docs remained engaged, but only for a very short period. Changing documentation practices months down the road was another matter. Perhaps they were more approachable when it came to queries, or even took a couple seconds to chat with a documentation specialist because of their presentation, but when you have been doing something a certain way for most of your career, it’s easier to revert to that practice rather than alter your behavior. The path of least resistance always wins.


Rounding with Physicians

Depending on the culture of your organization, this approach could really producer varying results. With a significant shift of more CDI specialists (CDISs) working remotely these days, I think for many organizations, this approach is becoming less and less common. I believe that there is significant value to a physician rounding with a documentation subject-matter expert, but here are some challenges:

  • Scheduling Limits: Your rounding schedule will have to align with the ever-changing schedule of your physicians, and that can be challenging. Depending on how many resources you have, your focus will have to be limited to physicians with the highest opportunity to improve severity capture at the point of care.

  • Time Limits: Physicians are usually very busy during rounding, especially when in a physician’s mind, the patient always comes first. Sometimes these rounds are teaching rounds, so residents are also present. You will have to be very strategic in your approach to get and maintain the physician’s attention on what you are trying to convey and be remembered. A longstanding, healthy working relationship with the clinician helps, so you should leverage that.

  • Behavioral Change: There is a risk that the physician might come to rely on your education efforts as a crutch, in the hopes that they would not have to change their behavior and that you would catch their missed opportunities. Don’t be a scribe; be a resource.


Online Training

With our industry relying more and more on technology these days, you would think that this approach should be at the forefront of how we can educate physicians. You would be correct, but here are some challenges that you may face:

  • Content: It is imperative to find content that takes the competition for a physician’s time into consideration. Online training needs to be concise, with no fluff, and allow physicians to take the training on their own time.

  • Engagement: Taking online training or a course still poses the challenge of getting physicians to participate, and if they do, it can be difficult to measure improvement if this method is not paired with some kind of performance monitoring (either via a documentation test or monthly reports).

  • Accessibility: Some forms of online training may not be readily available on a mobile platform, which can add to the frustration of physicians having issues being able to take the training. They want to be able to easily access the training, when it suits them, on the device they have with them at that time.

  • Behavioral Change: By now you may have noticed a pattern, or a “common denominator:” online training. If taken by the physician, it could turn out to be an act of checking off a box to make leadership happy, with minimal effect on actual documentation habits. The aim of providing education should be to change behavior, and really, you would be wasting your efforts if this was not the intended outcome.


So as you can see, there are many challenges associated with all modalities of physician training in clinical documentation, but that should not be a reason to exclude it as a part of your CDI efforts. Based on my experience, here is what seems to gain the most traction with physicians:

Any modality of training provided should be paired with a robust performance monitoring report, as well as feedback to physicians on their individual performances. It is well-documented that feedback promotes learning, and this is also true for physicians. Sharing credible data that compares physicians to their peers can be particularly effective.

Also, ensure that whatever training modality you adopt (sometimes it’s worth adopting more than one strategy), you make sure that the content is succinct, clinically relevant to recipients’ specialties, and paired with performance monitoring. When physicians realize that their performance monitoring report is measuring their performance based on content from the training, they are more likely to participate (even if retrospectively) with any training methodology you adopt.

To sum up: ignoring physician training and education on clinical documentation is too risky for your organization; but if it is not done correctly, you might as well not do it at all.

As Elon Musk said, “I think it’s very important to have a feedback loop, where you’re constantly thinking about what you’ve done and how you could be doing it better.”

Terrance Govender, MD

Terrance Govender is currently the vice president of Medical Affairs for ClinIntell, Inc. He has many years of clinical and healthcare management and consulting experience. Terrance has devoted his non- clinical career to improving the quality of clinical documentation provided by physicians by leveraging technology and analytics.

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