Working with doctors and developing relationships doesn’t just get buy-in from clinicians – it ensures data is accurate.
Nicole Draper is CDIA’s co-founder and is widely regarded as Australia’s foremost Clinical Documentation Specialist (CDS). She holds a Bachelor of Nursing, Master of Health Administration, and Graduate Certificate in Research. In 2016, Nicole set up Australia’s first CDI Program at a leading Sydney private hospital and began examining clinicians’ documentation. When tasked with analysing a cardiologist’s casemix data, she was surprised at the findings.
“This particular cardiologist was known to have complex patients and referrals from all over Australia,” Nicole says. “But when I sat down and I looked at the DRG splits, his patients looked…not at all complex. According to the complexity splits of the DRGs in his data, only twelve per cent of his patients grouped to the highest complexity DRG. And this was a big surprise to me, I’d been watching the work that he’d been doing, because it was pretty amazing stuff. To investigate further, I told him that I wanted to look deeper into his patient records. I wanted to determine if the clinical documentation was impacting the codes and DRG assigned, ultimately affecting the complexity of his patients represented in the data.” The objective was to find out whether the data was a true reflection of the patient cases.
“Of course, the cardiologist was horrified when I told him that only twelve per cent of his patients were complex. He felt really disappointed, because he works so hard. He’s one of those health professionals who is engaged with the hospital, who wants to be part of the fabric, and doesn't want to just be someone who brings patients in and take them out. He's there for the for the good of both the patients and the hospital itself,” she says.
After determining that the DRG split didn’t reflect his patients’ complexity, the next step was to find out why. Together, Nicole and the cardiologist examined the list of ICD-10-AM codes that had been assigned to each patient.
“I sat down with the cardiologist and explained how diseases are documented and coded. He was then able to think about how he was documenting patient cases for those episodes to be coded accurately and still really tell the clinical truth. He was able to improve his documentation which helped, not only the quality of his care, but the accuracy of his data.”
Nicole’s experience with the cardiologist highlights the important relationship between clinician engagement and data. In this case, by presenting the doctor with data from his own patients, Nicole had an immediate hook to get him interested and invested. Then, once he was actively engaging in CDI, his data became much more reflective of the clinical truth. It is very motivating for clinicians to see tangible results of their behaviour change.
This story of clinicians experiencing “data shock” when presented with the numbers of their own patient cohort is becoming common in hospitals around Australia.
“We're finding more and more doctors are noticing issues with their length of stay data, DRG split data, and casemix index. What they're finding is, pretty frustratingly, that it doesn't all add up. For example, there might be a patient who is very healthy and simple on paper having a complication, and it looks like they’re the kind of patient that shouldn’t have a complication, but in reality they are a multi-morbid patient and for that kind of patient the complication is pretty much an expected outcome. And, that obviously affects the coding accuracy and clinical truth.”
To avoid these issues, Nicole suggests the clinical documentation specialist (CDS) work directly with doctors and clinicians and aim to foster good relationships.
How to work with your doctors
Here are some effective strategies for educating doctors about the importance of CDI and explaining how their data is being reported and captured:
Nicole has some further advice. “Often as a CDS it’s worthwhile really getting your head around a couple of the key doctors’ data. Sit down and work with them. Meet with them. Understand how they work. For example, do they have a longer length of stay due to their clinical practice or is the complexity of their patients not being captured though the documentation.”
Furthermore, doctors who are actively engaged in CDI understand that these programs are the best way for data to be reported accurately. “Connect with these early adopters, as they are already interested in CDI and are keen about the quality and patient outcomes. They can help you reach out to other clinicians who are unfamiliar with the benefits of CDI.”
Other “Buy-in” Strategies
If you’re having trouble convincing your doctors that there’s a benefit to improved data, try some of these incentives.
Outcome Measures
Nicole advises that the impending introduction of publicly available outcomes data to Australia might catch clinicians’ attention.
“What we’re seeing more and more, is that doctors are becoming involved in CDI programs because they recognise that it’s the best way for their data to be reported accurately. And, at the moment, unlike the US, patients don’t have a lot of access to outcomes data. But that is definitely going to happen in the future.”
It might seem counter-intuitive that capturing more complexity, and sometimes complications, would lead to more attractive outcomes data. However, the outcomes data is risk-adjusted. This means that a clinician with comparatively more complications, but also a more complex patient population, will still be considered to have a good complication rate.
However, if a clinician is treating very complex patients, but the complexity of the patients is not accurately captured, it may look like the clinician has a high complication rate with a simple patient cohort.
Explaining this concept to clinicians, and that their patients currently look low risk on paper, is a great strategy to engage clinicians that might otherwise have not been interested in CDI.
Research
Nicole has seen that the relationship between data integrity and research is important to many clinicians.
“There are a lot of research studies that are done in our big hospitals based on retrospective coded data. With the mismatch between the clinical truth and the coded data, how do we know that the research decisions being made are accurate?”
Doctors make decisions every single day based on research. They use research to ensure they are practicing high quality, evidence-based medicine. Educate clinicians that research based on coded data is only as valid as the integrity of the data itself. This is likely to incentivise clinicians to see poor documentation as a real problem and make them want to get involved.
Furthermore, many doctors are clinician researchers, and, as experts in their field, consider contributing to the scientific literature a serious responsibility.
“So many doctors want to use their records for research,” says Nicole.
Nobody wants to publish research that isn’t useful, or indeed valid! Inform doctors of the mismatch between the complexity of their patients in real life and how they appear in the coded data. They will want to make sure that their own documentation, and therefore data, is accurate to ensure their research is legitimate.
The Big Picture
Nicole thinks it’s important to keep in mind the big picture.
“It’s important to remind doctors that the aim of a robust CDI program is to ensure all key stakeholders – from doctors to clinical coders – are capturing the clinical truth of who a patient truly is. Data integrity also helps to ensure better service planning and a more accurate basis for research projects – especially retrospective research.”
“CDI isn’t just about accurate DRG for funding. The data integrity is so significant.”
So use the data to engage the clinicians, and the clinicians will improve the data!
If this article is resonating with you? Contact us today to learn more about how we can help you enhance your CDI processes. Alternatively, do a good deed and share this with someone in your network who may be interested.