In this web series, HIM professionals working in emerging roles give advice on tackling difficult HIM problems.
The HIM Problem
As healthcare providers prepare for the transition to ICD-10-CM/PCS, ensuring the completeness of a patient’s record is more important than ever. However, HIM directors and the clinical documentation improvement (CDI) program specialists they work with can expect to encounter resistance from physicians who feel the extra training this involves is “red tape” that inhibits their time spent with a patient.
The Problem Solver
Dianne Haas, PhD, RN, executive director, consulting services, TrustHCS, which provides onsite training to CDI specialists and helps to launch CDI programs.
Step One: Upper Management
Support for CDI programs must start at the very top of an organization, otherwise you’re giving physicians ammunition not to be compliant, says Haas. That’s where organizational alignment comes in.
“Hospitals and physicians offices need a lot of rules,” Haas says, but while this is the case, there’s often the attitude of “nobody wants to upset the doctors by creating additional rules to follow,” and the rules go unenforced. That’s why it’s critical to start at the very top of the health system food chain.
“You need to start at the board of directors and help them understand that if documentation is not adequate in the record, to code to the greatest level of specificity in ICD-10, revenue is going to be affected. They should be involved with the C-suite leadership in looking at what their greatest revenue impact risk area is. There are lots of ways you can do that,” Haas suggests.
She adds that there are several tools on the market, as well as internal support staff, which can help pull numbers to assess where the revenue stream may be most at risk due to insufficient documentation.
“We also know that we need to engage very early on in discussions with medical staff and say ‘We’re all in this together,’ particularly if physicians are employed by the organization. If the revenue of the organization is jeopardized, the revenue that goes into their pocket is likewise jeopardized,” Haas says. “And so again, it’s back to this issue of people understanding the risk, understanding the alignment of how things tick and tie together.”
Step 2: Physicians
Although Haas works as a consultant, she still encounters resistance from physicians reluctant to adapt to the changes, and knows well the complaints HIM directors face when launching CDI programs—the most common being that it’s too time consuming or that it doesn’t flow well with an electronic health record (EHR).
She says physician frustration often stems from the fact that when they are trained on a new program, such as a new EHR platform, they receive a lot of intense, front-end loaded training prior to the launch, but then no one circles back one, or two, or six months later to say “Is this working for you?” or “Do we have to tweak it?”
“It’s not like we’re inventing CDI to irritate doctors… HIM departments, CDI departments and specialists need to be willing to listen to how things are going for the physician,” Haas says. “It can’t be all one sided. It has to be a bidirectional discussion and thoughtful engagement about how we make this functional and easier for everybody.”
But when—or if—physicians do resist CDI programs, an HIM professional’s response can vary depending on their relationship with the clinician. She recommends emphasizing the positives. An approach she has tried has been telling clinicians:
“Yes, it’s more complicated and onerous and time consuming, but we can save more lives, we can treat more effectively, and your documentation, whether you’re a nurse a doctor, a pharmacist or a physical therapist, needs to accurately reflect what you’re doing with the patient.”
Providing physicians with literature and studies showing the benefits of CDI can also be helpful.
Step 3: Follow-up
While physician cooperation absolutely is necessary for an effective CDI program, Haas also emphasizes the need for CDI specialists and coders to work together, adding that coders and CDI specialists aren’t just colleagues—they’re each other’s support structures.
Haas says one of the best CDI programs she’s ever seen in a hospital is one where the key leader has set a standard for CDI specialists and coders to meet daily to review the need for additional documentation requirements for which providers should be queried. They work as a team to reconcile their working and final coded DRGs.
“And it’s [the meeting] laser focused, a 15-30 minute meeting, but they are in sync with each other continuously, because the coders will look for things that the nurses might have missed, and conversely.”
With the ICD-10 Go Live looming on the horizon, forward thinking CDI directors might want might do well to start evangelizing benefits of documentation early on. Current fourth-year medical students will be the residents of 2014, starting their careers in the wake of ICD-10. Getting them to comprehend the need for complete, specific, and high-quality documentation early on benefits everybody, Haas says.
“Medical students will be on the hook for documentation,” she concludes.