By Jennifer Woodworth, Director, Clinical Documentation Integrity Program, Swedish Health Services
Physicians don't always realize the correlation between their clinical documentation and the level of credit they get for providing quality patient care.
No one chooses to work in the healthcare industry because it’s easy. We do it because we want to help others. The mounting frustrations doctors face as the result of an increasingly burdensome healthcare system are not only understandable, they are justifiable. These men and women did not go to medical school to sit through hours of meetings about code sets. Their primary responsibility is to treat patients. And for those of us who work with them, it is our role to be the trusted partner of our doctors and clinical care teams—to ensure they share the right information where and when it’s needed. I’ve spent close to a decade working with physicians on clinical documentation to make sure it reflects their intent and they get credit for the level of care they are providing.
Over the years, the doctors have taught me some valuable lessons. When it comes to implementing a successful clinical documentation improvement (CDI) program, start with these three fundamentals...
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By Jennifer Woodworth, Director, Clinical Documentation Integrity Program, Swedish Health Services
Physicians don't always realize the correlation between their clinical documentation and the level of credit they get for providing quality patient care.
No one chooses to work in the healthcare industry because it’s easy. We do it because we want to help others. The mounting frustrations doctors face as the result of an increasingly burdensome healthcare system are not only understandable, they are justifiable. These men and women did not go to medical school to sit through hours of meetings about code sets. Their primary responsibility is to treat patients. And for those of us who work with them, it is our role to be the trusted partner of our doctors and clinical care teams—to ensure they share the right information where and when it’s needed. I’ve spent close to a decade working with physicians on clinical documentation to make sure it reflects their intent and they get credit for the level of care they are providing.
Over the years, the doctors have taught me some valuable lessons. When it comes to implementing a successful clinical documentation improvement (CDI) program, start with these three fundamentals:
Skip the catering: meet your doctors where they are
Everyone is busy, especially doctors, and initially, we tried to engage with them by holding early morning meetings where we provided breakfast and information about our CDI program. We quickly discovered that we were left with not much more than a tray of cold eggs and pancakes. So we made adjustments and began meeting doctors where they were—in their departments, on grand rounds, and within the agenda of a medical staff meeting. This significantly improved physician engagement and helped us better collaborate on capturing the patient’s care in a way that was accurate and complete not just to other doctors. CDI programs are not one-size-fits all, and keeping this in mind as you reach out to your physician teams is very important.
Become a translator for health IT language
Because specialty groups each have their own medical vocabularies, different registries, and workflows, they will also face unique challenges and concerns. Swedish Health Services is a multi-hospital health system that includes a heart and neural hospital. When we implemented our CDI program, we realized that we needed to tailor our approach by physician specialty—what was an important quality driver in one clinical area, is not necessarily the same in another. Swedish is a “5-star institution,” and we need uphold that reputation, so, in order to do this, we first had to figure out what each specialty group’s quality scoring was based upon, and then sit down and work with our physicians to show them the impact their documentation was actually having on their scores.
Seeing clinical data is believing
Doctors have analytical minds, after all, that’s how they decide how and when to modify treatment plans—by looking at results and analyzing the data. This holds true for clinical documentation, too. They don’t always realize that how they document is just as important as how they are providing care; in fact, it’s the proof they are doing the right thing for patients. When we reviewed our clinical data, we found that our ICU patients were typically on ventilators longer than the average, which was negatively impacting our quality scores. Sitting down with our ICU physician team, we conducted a retrospective review and discovered that the majority of these patients had pre-existing respiratory conditions that necessitated an extended time on a mechanical ventilator. It wasn’t that they weren’t receiving good treatment, it was, in fact, our doctors doing the right thing for these patients—keeping them on the ventilator longer because they needed it— that was negatively skewing our numbers. It was a simple error of omission: our doctors didn’t realize that by not fully documenting their patients’ pre-existing conditions in the clinical record, they were hurting their reputation as great doctors, and ours as an excellent hospital.
While not always easy, changing a culture to support a value-based care model makes sense: hospitals and healthcare organizations get paid, or not, based on how they care for their patients. Our physicians trust us to help them accurately represent the good care they are providing and in turn, we use CDI data to identify areas where together we can optimize quality to do what’s best for the patient.
The accurate clinical data that results from an effective CDI program not only helps our doctors earn credit for the good work they do, but also improves patient care and reimbursement for our organization. Accurate clinical data also enables us to get a clear picture of who our patient population is so we can adequately prepare for their future health needs. And, at the end of the day, that is what healthcare and the continuum of care is all about.
About The Author
Jennifer Woodworth is the Director, Clinical Documentation Integrity Program (CDIP) at Swedish Health Services in Seattle, WA. This blog originally appeared on Nuance Communications’ blog, What’s Next.
