Physician Education for Clinical Documentation Improvement

Clinicians undergo rigorous medical training followed by years of residency and fellowship programs.  While the training focuses on practice of medicine, it often places little emphasis on how to accurately document patient encounters.  Furthermore, frequent changes in payer rules and documentation guidelines call for constant familiarization with the latest regulations.  The associated administrative burden leads to suboptimal documentation.  While traditional modalities of audits and periodic training programs show some promise, millions of dollars in revenue are still lost due to documentation gaps and compliance issues.  Of late, CDI education is proving to be an effective way to improve physician documentation.  Healthcare facilities are now considering continuous physician education as an integral part of their CDI efforts.  Digital-age solutions such as RevCDI-led coding from Reventics improve physician engagement through customized education within the EHR and through a combination of continuous chart level feedback, self-directed modules, tip sheets, webinars, and on-demand videos in a non-intrusive manner, while improving clinical documentation integrity.

Physicians are required to document a large amount of information to get credit for the work they have done, however due to time constraints and/or lack of education, they sometimes fail to use the ideal words to provide the highest level of specificity to services furnished.  Excessive time spent documenting is one the biggest challenge to physicians when it comes to patient care.  The disconnect between real clinical care and its failure to often align with the precise information required to capture coding as well as change in insurer policy often leads to physician burnout.  According to the American Health Information Management Association (AHIMA), incentive programs, customized physician education, and providing physicians with the most appropriate time to access and complete medical records are effective ways to improve physician documentation.  Competition for a physician's time is fierce and getting them to attend an online CDI education session is unlikely to be a high priority.  RevCDI allows a scalable model of getting precise feedback to physicians in a timely fashion with limited disruption to the physician’s workflow.

Engagement is Key:

Each physician is unique.  Similarly, no specific modality of physician education is appropriate for all physician practices.  Physician educational interventions must be designed based on a particular physician's needs and bandwidth.  Physician engagement is the first step to a successful CDI education program.  Non-intrusive and well-timed instructive interventions provided within the workflow can engage physicians better.  It is crucial to provide customized education to physicians through a variety of modalities delivered across various platforms at convenient times.  Delivering summary at physician level as well as group-level insights to administrators and physician educators through role-based access enables creation of focused and individualized education plans.  Also, offering an end-to-end automated workflow ensures physicians engage better with the education program.

Physician-to-physician Learning

One of the most effective ways to maximize a physician's skill sets to improve documentation is through physician-led training.  Every physician traditionally undergoes professional training under another physician at some point of his or her career.  It is well established that a physician can understand another physician's strengths and shortcomings better than non-physician staff.  A physician can comprehend and articulate another physician's language better and design an educational program focused to the point, making it more interactive and engaging.  Physician-led learning, specifically when delivered under an experienced senior physician who is also an expert in the subject, can help achieve the goal of improved documentation practices, subsequently improving compliance and revenue.

Customized Tip Sheets:

Providing physicians with tip sheets are a great way to improve documentation.  Unlike boring instruction sheets, tip sheets are customized to be visit type and physician specific.  Tip sheets are delivered digitally at the physician’s convenience and offer quick up-to-point tips on how to accurately document patient encounters.  They are non-intrusive and engage physicians better to remind them of the key elements to capture the precise data required for compliant coding and reporting.

Performance Reporting

Measuring progress becomes tedious if the training is not complemented by robust performance monitoring.  Feedback promotes learning and any type of CDI training provided to physicians must be paired with detailed performance reporting as well as feedback on individual performances.  Performance must be evaluated in the context of clinical quality measures as well as utilization best practices to identify opportunities and provide improvement inputs.  With most physicians eager to know how they fare compared to their colleagues, sharing credible data can be very effective.  It increases physician participation in training programs as they are aware their performance is measured based on content from the training program.

How Reventics Can Help

Accurate documentation is the single most important component that accounts for a physician and his or her healthcare facility’s ability to substantiate quality of care, submit appropriate claims, and defend medical necessity.  RevCDI-led coding from Reventics goes far beyond historical traditional methods of clinical documentation improvement.  Powered by AI, RevCDI provides the best source of education to physicians as an added value.  It offers regular, direct chart-specific feedback communication and customized education materials to physicians based on historic clinical documentation deficiencies through a combination of self-directed modules, tip sheets, webinars, and on-demand videos delivered via Web, Mobile App and within the EHR.  Reventics’ deploys its Chief Medical Officer led clinically focused team comprised of physicians to design the content as well as engage with clients.  RevCDI also provides performance reporting on compliance and comparative dashboards on deficiency levels in a simple and meaningful way.