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2 The CDI Profession: Results of a Research StudyGary C. David, PhD Associate Professor of Sociology Assoc Professor of Information Design & Corporate Communication Bentley University, Waltham, MA
3 About the Presenter Gary David (PhD – Sociology) is the project coordinator for the Bentley University project on the creation and use of healthcare documentation. He has studied the work of medical transcription, the uses of speech recognition technology and EHRs, physician attitudes regarding medical records, the work of clinical documentation improvement specialists, and others who routinely make use of healthcare documentation.
4 CDS Project DescriptionFirst academic project to examine the work of clinical documentation (improvement) specialists Goal is to understand the knowledge work entailed in CDS profession, and the role it plays in production and usability of medical records Part of a larger ongoing project examining the production and use of clinical documentation (e.g., medical records)
5 The Medical Record A patient’s health record plays many important roles: It provides a view of the patient’s health history. In other words, it provides a record of the patient’s health status (sickness and wellness) including observations, measurements, and history and prognosis, and serves as the legal document describing the healthcare services provided to the patient. It provides a method for clinical communication and care planning among the individual healthcare practitioners serving the patient. It provides supporting documentation for the reimbursement of services provided to the patient. It documents and substantiates the patient’s clinical care and serves as a key source of data for outcomes research and public health purposes. It serves as a major resource for healthcare practitioner education. It serves to document evidence of the quality of patient care. It serves as the legal business record for a healthcare organization and is used in support of business decision-making.
6 Healthcare Documentation Makes Healthcare PossibleDoctors Lawyers Coders Auditor Research Health workers Patients Reimbursement If it isn’t written down, it didn’t happen Doctors don’t generate revenue; documents do
7 Ethnographic Studies of WorkThe area of ethnographic studies of work, or workplace studies, has been specifically applied to examine the use of technology in the workplace More generally, workplace studies refers to an approach in which the activity of work is examined as an everyday activity taking place within a specific context Less concern is given to descriptions of work and more attention to how work is actually done
8 Limitations of Job DescriptionReviewing medical records for the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff … Sample actual job description Formulate clinically credible queries Effective and appropriate communication with physicians Communicates with HIM staff and resolves discrepancies Organizational, analytical, writing and interpersonal skills Part of the goal is to understand what these kinds of tasks mean in practice in terms of how people do them.
9 Data Collection (Thus Far …)Attendance at 2011 ACDIS Annual Conference Presenting at 2012 ACDIS Annual Conference Interview with 27 CDSs Member of the ACDIS certification advisory board Developing site visits to observe CDS work
10 Some General Findings
11 The CDS Job Basically, the job of the clinical documentation (improvement) specialist is to make the patient look “as sick on paper” as s/he is in “real life” … … in a way that is institutionally or administratively (versus clinically per se) recognizable and accountable
12 CDS Characteristics & PersonalityQ: What kind of personality traits or characteristics does a CDI have? Inquisitive, investigative, and analytical Good clinical background (critical care) Strong interpersonal communication skills and able to engage in relationship management Assertive and confident Patient
13 Best Aspects of Job Q: What are the best aspects of your job?Interesting work, constant learning Autonomy of the job Commitment to idea of quality documentation Detective part of it, “CDI as CSI” Face-to-face work, being on the floor Financial impact on the hospitals
14 Worst Aspects of Job Q: What are the worst aspects of your job?Salary doesn’t match the financial impact of the work Dealing with the doctors Metrics can be burdensome Better recognition of work they do Better technology to support their work
15 What Is Needed for Profession to Advance?Q: For CDIs to advance as a profession, what kinds of things should be done? Need to be more vocal about their contribution People need to understand work and why it is important Strong administrative and institutional support of work Team approach to documentation Certification
16 Specific Finding: The Query
17 The Query A query is defined as a question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record. AHIMA: Managing an Effective Query Process Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator). Not specific, incomplete, conflicting, or ambiguous TO WHOM?
18 Query Format RestrictionsCannot be leading in nature “Is the patient suffering from x condition?” Cannot introduce new information not in the record “There is an additional lab report that indicates x.” Can ask for clarification and specification without leading “Can you provide a (more specific) diagnosis?” However, How much time do physicians have to devote to responding? What does this do to the perceived clinical competence of CDS? Does this affect how the CDS is seen as part of the medical team?
19 Verbal vs. Oral Queries The Query Format It is recommended that the healthcare entity’s policy address the query format. A query generally includes the following information: Patient name Admission date and/or date of service Health record number Account number Date query initiated Name and contact information of the individual initiating the query Statement of the issue in the form of a question along with clinical indicators specified from the chart (e.g., history and physical states urosepsis, lab reports WBC of 14,400. Emergency department report fever of 102) It is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded. The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure , or secure IT messaging system. The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure , or secure IT messaging system. AHIMA: Managing an Effective Query Process
20 Physician Resistance A potentially typical attitude regarding requests for increased specificity and changes to documentation habits Let's say that the status quo could remain if you don't do it. So you have no cudgel. There is no cudgel over the physician. Well, you say this hospital might close? They just say, "Well, get out the phone book. Look at all the other hospitals around here. In fact, I'm credentialed at three of them already.” They say, "I am not making this effort. I've been practicing for 30 years and if you think I'm going to change now, you're crazy." CDS005
21 Relationship Building and Rapport DevelopmentThe importance of face to face in order to build relationships They're absolutely on the floors. That's where we like them. That's their daily job, and I want our CDS nurses on the floor because they're building these individual relationships with these physicians. They're assigned to specific floors or units with the same physicians day after day, week after week, so you build that kind of rapport and trust and respect that they can gather. And like I said, all of our CDS nurses, they've probably got 100 years between them so they've been here all of them forever, and so they know all these physicians and already have a good rapport. So them having one-on-one face time on the floor is very important. CDS008
22 Importance of Verbal QueriesBy engaging directly through verbal queries you can build a relationship and trust You have to build trust and you have to build a relationship, is what you have to do. And you have to be able to do that because it’s a big part of the job. You have to be able to communicate so that they understand because it is a different way of looking at things and thinking about things. And they have in there what they want to say and what they need to communicate about their patient, and then you have someone saying to them, "Well, you have to write it like this." Well, how many people are going to remember that when they're seeing how many patients a day? So it’s being able to always give them tips or know that you're there. Let them know that you're there to help—you're there to support them. CDS027
23 Importance of Verbal QueriesIt is often preferable to do queries out “on the floor,” especially in educational situations I think we encourage verbal querying quite a bit because I think that clinician-to-clinician conversation really opens up some important dialogue. But realistically, with as many practitioners and folks that we have in that record at any given time—how fast-paced it is—it's not always possible, but it is ideal, especially if you have a newer physician with a question which I still hear quite a bit. We have a lot of compliance restraints as to how we pose questions, and quite often that face-to-face conversation is what we need to be able to gain the understanding. CDS025
24 Demonstrating Clinical CompetencePart of the task for the CDS is to display clinical competence so physicians will trust their judgment, give their time to entertain queries, treat their requests seriously, and respond when requests for clarification are made
25 Demonstrating Competence and PBJ SandwichesA: I took two pieces of bread, put peanut butter on one side and jelly on the other, put the pieces together, and ate it. CDS: But you never said it was a sandwich. You never said what kind of sandwich. You didn’t say what kind of peanut butter you used, what brand, crunchy or creamy, organic or not. And what kind of jelly? Or was it jam? And where did you eat it? Etc., etc., etc.
26 Educational OpportunitiesVerbal queries as teaching moments It's almost like a mentoring because you have the experience and knowledge, and you are privy to conversations because you're sitting there working with your back all the time, and you're kind of acclimated, I guess. They know who I am. I'm always on the floor, in the corner, looking at charts, not talking to anybody, just typing away on our laptops. And you become acclimated to the environment. Well, conversations take place all the time, and you might be privy to them whether you're supposed to or not. And a lot of times when there is misinformation, especially between two young nurses, and you might have read that chart from front to back and know exactly what it said. Or there's confusion between the social worker and the nurse: You help to clarify if they came from a nursing home, and you help them out with that. CDS012
27 Moving Toward Written QueriesQueries can be performed remotely after these relationships have been established Again, not in the beginning; I don't feel that any program bringing on CDI because the relationship is so valuable when you're first starting out to get everyone to figure out what you're doing. But eventually everyone will have CDSs so there will be no relationship building ... well, I shouldn't say there will be no need for it. But really, truthfully, it can be done off-site. The doctors will realize they need the clarification: Do you mean this? Yes or no? I don't care if you say no, but just respond to me. So yes, I see a point where it can be done. CDS020
28 Other Process Management Issues in StudyInternal vs. external hires Distributed vs. located work Clinical vs. nonclinical backgrounds In-house vs. outsourced Clinical vs. billing focus of programs
29 Project Next Steps Write up and submit findings to academic outletsDeepen understanding of communication processes “Benchmarking” of various CDI programs Longitudinal case study of CDI programs Develop applications of project findings
30 Webinar: Intrinsic vs. Extrinsic Motivations for Behavioral ChangeThe question: How do you get physician buy-in and long-term behavioral change? The obstacles: Workplace culture, professional norms, institutional defiance, recipient design (amongst others) Webinar being developed with Prof. Duncan Spelman (Professor of Management) for ACDIS on this topic
31 Questions? [email protected]In order to receive your continuing education certificate for this program, you must complete the online evaluation which can be found in the continuing education section at the front of the workbook.