Using data to drive physician engagement

"You are your own best teacher," or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers’ own records.

With pay-for-performance and other quality initiatives underway as a part of healthcare reform, physicians need to see how they are performing in real time. Showing them this data in comparison to their peers demonstrates through real numbers how they stack up, says ACDIS Advisory Board member Robin Jones, RN, BSN, CCDS, MHA/Ed, system director for CDI at Mercy Health in Cincinnati.

Query responses

Until recently, most providers were not interested in seeing how unanswered clarifications or conflicting DRG assignment affected metrics, Jones says. CDI programs traditionally measure overall success by tracking items such as:

• Query rate (overall and by CDI specialist/physician)
• Physician response rate (overall and by CDI specialist/physician)
• Physician agreement rate (overall and by CDI specialist/physician)
• CC/MCC capture rates
• MS-DRG shifts
• Case-mix index changes

This data isn’t often shown to physicians, and yet, since queries represent the single most important tool for CDI programs, gleaning patterns of information from them often illuminates opportunities for improved physician support. For example, a lack of response from a particular physician might represent an opportunity for education or a change in approach, or the need for a new method of communication (e.g., notifying the physician of an outstanding query through a phone call rather than email).

Mercy’s CDI program lists physicians’ clarification response rates and places them in physician lounges for all to see, says Jones. To keep the information anonymous, the CDI team assigns each physician a number so they can quickly and safely gauge how they are performing in comparison to their peers.

"When physicians see their rate is lower than their peers, they hurriedly find our CDI supervisor," Jones says.

Mercy also provides physicians with an individualized list of DRGs assigned to their patients, so they can cross-reference that information to their own private billing.

Case studies

CDI programs can elevate the importance of data by tying it to case studies?real scenarios relevant to patient care, says ACDIS Advisory Board member Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP, director of education at Med- Partners based in Tampa, Florida.

Additional elements

Show providers an example of poor documentation, then compare it to the same case with improved documentation and show how the improvement affects a variety of metrics, Newhouser says. Collectively, members of the ACDIS Advisory Board suggest sharing information regarding the following data points:

• Severity of illness/risk of mortality (ROM)
• Length of stay (LOS), average LOS, geometric mean LOS, and expected LOS
• Readmission rates
• Observed over expected mortality ratio

Be transparent so physicians can see the benefits?both financial and quality-related?of precise documentation, Newhouser says.

"Physicians need to know that the money is important if they want to have a hospital to practice in, updated equipment, and a paycheck," she explains. But, "it is imperative to remind them that while money is important, it is quality that must come first."

For each metric, consider the data for the facility as a whole, and compare it to other facilities within the system or region, says Michelle McCormack, RN, BSN, CCDS, CRCR, director of CDI at Stanford (California) Health Care. Sharing such information with the physicians illustrates how their documentation affects the larger hospital community.

Then, drill down into the data to identify individual metrics, comparing physicians against one another within the facility and within a particular specialty or service line, says McCormack.

External analysis

Beyond simply showing physicians the data, CDI teams must teach providers how documentation and coding affects their personal profile as well as their facility’s standing, says Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Phoenix. A host of consumer websites cull data and employ a variety of algorithms to rank physicians and hospitals?many of these are well known, such as CMS’ Hospital and Physician Compare sites, Healthgrades, and Leapfrog.

Understand how those practicing within your facility measure up in these reports and share important milestones as necessary, Schade says. When positive shifts occur that correlate with documentation improvement focus areas, tout those accomplishments and acknowledge the role the physicians play.

"Physicians will be engaged if they understand how documentation and coding impacts their personal profile," Schade says. "Physicians are by nature competitive, and so they aim to be high achievers." CDI programs can use this to their advantage.

Nuanced details of these reports need analysis, warns Paul Evans, RHIA, CCS, CCS-P, CCDS, manager for regional CDI at Sutter West Bay in San Francisco.

For example, The San Francisco Chronicle recently published raw mortality outcomes data for the region. Since the paper did not understand how observed versus expected mortality plays a role in telling the story of a patient’s care, its analysis left a tertiary care center in the Sutter family looking as though it had worse mortality rates than its competitors despite the fact that it treated extremely sick patients, Evans explains.

"You have to be careful to compare apples to apples," Schade agrees.

With internal data in hand, Evans showed the high-level ROM of that facility’s patients and demonstrated that the facility actually outperformed its competitors.

"Unfortunately, you can’t explain statistics and ROM to the typical layperson, but you certainly can communicate it to your staff and to your physicians," Evans says.

Data discretion

Some data discretion may be warranted. Choose data elements that are most relevant to the CDI program’s goals at the time, as well as targeted to the specific physicians in the audience. Remember to share success stories with data elements as they are reached.

"CDI managers should consider all data points and make sure the numbers they present to the physician accurately represents the message they need to convey and targets the needs of the physicians themselves," says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, director of CDI services at Enjoin.

For example, if a service line that has not been responding to queries begins to consistently increase its response rate, include the improvements in that response rate along with the other metrics you present, McCormack says.

"You want to select metrics that will allow you to see progress as well as areas of opportunity," she says.

It can be difficult to choose which data points to share, McCormack says, but sharing such concrete analysis leads to greater support from physicians overall.

Editor’s note: This article originally appeared in the CDI Journal. For any questions, contact editor Amanda Tyler at [email protected].

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