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Obtain medical staff support for OP-CDI with these strategies

HIM Connection, May 2, 2006

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The first step in designing on outpatient clinical documentation improvement (OP-CDI) program is to consider the needs and wants of the physician-the source of your documentation. Although the basis for moving forward with physicians will apply generally to all physicians, an organization's specific strategy will depend upon the form of relationship the organization has with its physicians. The following strategies will help your facility design an OP-CDI that is most effective for you.

• Focus on "getting it right the first time"
  In the outpatient setting the brevity of the patient encounter necessitates that an organization's OP-CDI program focuses on getting the documentation right the first time. One of the goals of every OP-CDI program is to decrease denials due to lack of medical necessity (documented correctly). Another goal is to increase the accuracy of ED leveling based upon complete and accurate documentation in the ED. In each of these encounters, the amount of time the physician has with the patient is very limited. In the case of a lab "visit," the face-to-face encounter time can be as little as a few minutes.

  For these reasons, it is important to design an OP-CDI program that, through the use of automated data collection, streamlined formats, economies of scale for the services like lab and other diagnostic testing, results in documentation that ensures the physician is "getting it right the first time." By designing a program that is focused on getting it right the first time, the amount of time required from either hospital's staff or the physician's is minimized.

• Involve physicians in the design process
  Physicians generally relate better to other physicians than they do to non-physicians. In order to get the greatest success out of any OP-CDI program, the hospital should include physicians in the design teams for all OP-CDI tools. This is particularly important in the designing of electronic data collection tools-such as the kind that physicians can use in their hand-held devices. A large number of physicians in the ED environment currently use such devices. It is important to involve willing physicians in tool development.

  This practice mimics the practices of manufacturers who enlist the assistance of the end user (the consumer) to create a new product or upgrade an existing product. Successful organizations know that the customer defines quality. In the healthcare organization, certainly the patient is the primary customer. However, within the context of OP-CDI, the physician is the customer and the end user of all tools that will be developed. Moreover, like the manufacturer who "needs" the consumer to purchase his product, the hospital "needs" the input from the physician (in the form of documentation) to improve the revenue-generation process.

• Share publicly-available data about your hospital (good and bad)
  By sharing publicly-available data about your hospital, like the graphs provided on www.healthgrades.com, with physicians on a regular basis, you maintain that their documentation affects data in front of them. This practice, if it becomes a regular one, can also be a positive one.

• Offer continuing medical education courses (CMEs) that focus on documentation improvement
  In the discussion above, we focus on the value of providing educational sessions to physicians on documentation improvement and risk management. Organizations should have a minimum number of CMEs that are documentation-improvement related each year. And, the advertisements for the CME sessions should clearly state that the purpose of the session is to improve documentation. This approach will continue to inform physicians about the importance of their documentation practices.

Editor's Note: This article was excerpted from HCPro, Inc.'s book Guide to Outpatient Clinical Documentation Improvement: The First Step in Revenue Cycle Management written by Ruthann Russo, JD, MPH, RHIT. For more information or to order go to www.hcmarketplace.com or call 877/727-1728.

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