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Tip: Use measurable results to get reluctant physicians on board

CDI Strategies, October 18, 2007

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Some physicians will always be resistant to clinical documentation improvement programs, but Colleen Garry, RN, BS, clinical documentation manager in the health information services department of the Medical University of South Carolina (MUSC) in Charleston says the best way to break down the barriers is to demonstrate results.

For example, one of MUSC's service lines had a lower complication/comorbidity (CC) capture rate than its benchmarks indicated. The physicians were surprised, given that the acuity of the patients they treated warranted additional CC assignment. As it turned out, much of the data needed to capture the additional CC's was already in the record, it just wasn't in a codeable format. It proved to be a relatively easy fix that brought immediate results.

"Give them [physicians] an understanding of what documentation you're looking for, and what's wrong with the documentation in the record, and you'll get better results," Garry says."

Garry also recommends finding common ground--i.e., data for which physicians are personally invested. For example, Garry says the MUSC medical director works with physicians to improve their mortality index and quality outcomes data. This is important data for the hospital, too. "The more you can show how each goal builds on the other, the better," she says. "Trying to pitch the program as a financial incentive for the hospital [doesn't work]."

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