Get physicians in on improving documentation

Tailor education efforts to facility's needs, case mix

Adapting to the sweeping changes in reimbursement mandated by the new MS-DRG system may be like suddenly having to drive on the left-hand side of the road, says Bert Amison, managing director for health care advisory services at KPMG.

"There's going to be a learning curve for all hospital staff since everything has changed. Hospitals are rightfully concerned about the new system, especially that they may not document correctly in the ramp-up period. This means that they must come up with a strategic plan for adjusting to the new system and helping people get up to speed," he adds.

There's no cookie-cutter approach to education, Amison says. Any kind of education program should be based on the individual organization, its needs, and its strategic vision. Otherwise, the educational efforts will be hit-or-miss, he adds.

"Hospitals need a plan vs. just throwing education at case managers and throwing education at physicians. It's not a good idea to spend resources either internally or externally on education where the curriculum is not tailored to the specific organization," he says.

Don't try to educate the hospital staff on the entire MS-DRG system all at once. Start with the areas where the new reimbursement system will have the biggest effect, such as your top 10 or top 20 diagnoses, suggests Carol H. Eyer, RHIA, senior manager of clinical compliance and reimbursement with Pershing Yoakley & Associates' Atlanta office.

"Offer the MS-DRG changes in small doses, starting with the areas where it will have the greatest projected impact on the hospital's bottom line, whether it's positive or negative. If you try to teach everything at once, people either won't absorb it or may tune you out entirely," she says.

Challenges to implementation

When it comes to implementing the new MS-DRG system, the biggest challenge continues to be the physicians' role in documentation improvement efforts, says Eyer.

"Case managers and the health information management staff have been the ones to sing the song that documentation is important with every quality initiative coming down the pike and each passing year. So physicians will be hearing what sounds like a reprise of the same thing, despite the fact that this is revolutionary," she says.

The challenge for physicians is not any different from what it was a year ago or five years ago, Eyer points out. They must document correctly in order for the patient's condition to be coded accurately and the hospital to be paid correctly.

Some of the new and more specific coding-related verbiage required with documentation under the new MS-DRG system may be foreign to many physicians compared to the past, she adds.

But one thing hasn't changed: Coders are not clinicians and cannot make clinical assumptions. They cannot look at the medical record, pick up on something in the chart such as a lab value or other diagnostic result and assume that the patient's condition falls into a certain severity level.

"The same official coding guidelines apply as prior to MS-DRGs. If it's not documented clearly and by the physician, it can't be coded," she says.

"Hospitals must establish a physician education program, whether it's inservice or by an outside consultant, to help physicians understand that it is their documentation, and only their documentation, that coders can use for coding," Amison says.

One of the best approaches to getting physicians on board may be to bring in an outside resource, preferably a physician who is a consultant and who can connect at the physician level to supplement the activities of both the coding and case management staff, Eyer suggests.

"The physicians have been hearing this message from the coders and case management staff for a long time. The ideal person to educate them on the MS-DRGs will be a physician who hasn't been out of practice for too long and who understands physician priorities and can speak to what is really important to them, to their patients, and to the hospital," she says.

When the information comes from a fellow physician or colleague, rather than a case manager or coder, doctors are more likely to accept the information and process it, she says.

An alternative would be to recruit a physician champion internally who could work with hospital case management, health information managemen, and coding and serve as a physician resource on documentation issues, Eyer suggests.

Hospitalists who are constantly seeing acute care patients in the hospital have a substantial opportunity to affect documentation and may become the champions you need to create an educational program internally, suggests Deborah Hale, CSS, president of Administrative Consultant Services Inc., a health care consulting firm based in Shawnee, OK.

Even if case managers are not responsible for physician education, they should be involved with the planning and rolling out of the initiative, especially if they already are involved in a documentation improvement program and have worked with the physicians on documentation, Amison says.

He suggests that the case managers speak for a few minutes at the inservices, tell the physicians what they may see in terms of queries, and turn it over to the speaker who is going to explain the new system.

Physician inservices don't have to be delivered by a physician; but peer-to-peer education is very important and most physicians respond better hearing it from a peer than someone in another discipline, he says.

"Physician champions can be very successful in the role as a liaison between the physicians and the case management department," he says.

Don't put physicians on the defensive when it comes to documentation, Hale says. The person who is presenting the educational session has to present the information in a way that achieves their buy-in in order to be effective, she adds.

In large hospitals, it's difficult to communicate with the entire physician staff all at once. Hale suggests starting with small groups, preferably by service line, and tailoring the education specifically to the specialty.

Involve the medical executive committee in your educational efforts because they can become the driving factor for documentation improvement, Hale suggests.

The approach to physician education depends on the organization, says Amison, who recommends tailoring the educational efforts to what has worked in the past.

"Some organizations have well-attended physician meetings. Others have found more success in having after-hours dinners or breakfast meetings before rounds for educational sessions," he says.

Keep the information relevant to the physicians, he advises.

"Talk about documentation within the specific area that makes a difference in the record so the coder has what they need. Don't overpower doctors with too much coding detail or too much information about the impact to the hospital, operationally or financially," he says.

Instead, emphasize what it means for the physician's personal profiles with managed care companies that compile preferred provider lists.

"Show them what will mean something to them in today's world," he says.

One technique for educating physicians on documentation improvement is to create case studies that typically apply in your hospital, Hale says.

Show the impact of documentation by using case studies with examples of how improved documentation results in better reimbursement and how it affects the case mix index and most importantly, the hospital's standing on public report cards, she says.

"Physicians have long asserted that their patients are sicker than other patients. With the new MS-DRGs they'll be able to demonstrate this more than before, provided they document accurately," Eyer says.

Eyer suggests pulling up some of the public report cards to show how they are affected by how well the physician has documented the severity of illness.

"If physicians can connect that their documentation leads to the codes that drive accurate MS-DRG assignment, and that further, this generates data accessed and published on the various health care quality and monitoring web sites, this may help them understand the importance," she says.

Drill down to specific clinical examples of how proper documentation can affect quality outcomes for the specialties of the physician group you are addressing to bring it even closer to home, Amison advises.

"Don't dwell on the financial impact to the hospital but it is a good idea to include a little of that so they understand that the hospital has a lot at stake," he adds.

Show them what the proper documentation can mean to them from a quality outcomes perspective and how it can affect physician report cards, Amison says.

"When the doctors are accurately documenting everything that is appropriate to the patient stay so that the chart truly reflects the resources spent and the conditions they considered as they worked their way through the patient care, the coders at the end of the day will do their job," he says.

(Editor's note: The views and opinions expressed herein do not necessarily represent the views of KPMG LLP.)