Physician standards
Our administration has recently begun discussing ways to incorporate the answering of queries into physician expectations/contracts. Does anyone have any measurable standards they use, that you wouldn't mind sharing? I want to include: answering within a specified time, including the answer in the discharge summary as well as the progress notes, include POA if a new diagnosis is given...
I have lots of requests but want to ensure they are written in a measurable way.
Thanks!
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
I have lots of requests but want to ensure they are written in a measurable way.
Thanks!
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Comments
Kindest Regards,
Mark N. Dominesey
Perhaps you're breaking relatively new ground?
This ACDIS poll might be interesting to you (if you'd not already seen it):
Are your queries part of the deficiency or suspension process at your facility?
http://www.hcpro.com/acdis/view_readerpoll_results.cfm?quiz_id=2360
Don
Don, if you will send me your contact info, we can discuss this further.
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
I would be interested in this information as well! We currently contract with a hospitalist company to provide coverage for our patients, so in essence they are our employees. Currently, I know we have expectations built into their contracts related to Core Measures, but we do not have anything in place for Coding Queries or CDI queries. Our Administration supports our CDI efforts and the need for all of our employees to comply with our hospital standards, so I would like to see how other CDI programs are measuring outcomes and providing feedback.
I am also interested in this topic because of the recent article in "Today's Hospitalist" magazine September 2011 "Beware of Leading Queries" (if you haven't read it... please Google it and enjoy...)
Under the section "Perverse Incentives" by Kenji Asakura, MD states:
"The risk for clinicians is further compounded by practices that many hospitals employ. One practice in particular involves measuring your response to queries- referred to as query response rate or query agreement rate-and giving you a report card on those responses. Some groups even peg some portion of physicians' quality bonus to their query response rate.
But such practices can create a perverse incentive by encouraging you to go along with queries as written. Also, because properly responding to queries can be time-consuming, a strong focus on query response rates creates even more of an incentive for busy clinicians to simply sign off on them. And the fact that many hospitalists are employed by their hospitals makes them easy targets for performance improvement initiatives in the form of a report card or incentives."
Keep us posted on what you find helpful! -V
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
We do not use "check box" queries, so our physicians have to actually write something into the record. Many times it's difficult to tell if they just don't feel further documentation is needed or if they are ignoring the query. Another problem we have is one physician answers the query, but then the next one coming on doesn't pick up that diagnosis, then the next one does, and so on. Charting is just very inconsistent with that group - even if there is not a query on the record. For example: admitted with HCAP, this gets documented for 2-3 days, next physician says no PNA, purulent bronchitis, but cont the 3 IV abxs. At the next rotation, we get HCAP, no bronchitis, DC antibiotics, then the DC summary says...You get the picture.
Another example is renal fail, renal insufficiency. One says failure, the next day it's insuff, the next we are back to failure.
The goal is not to measure the number of "agreed" with queries, but just to have them answer something and to be consistent throughout the record. In the case above, even if the DC summary says PNA, what would RAC think since the charting reveals yes we do, no we don't documentation? I also understand that as new information becomes available, the physician may need to change the diagnosis. But the above example is the norm not the exception here. Every physician has their preferred verbiage and they use that even though it may be inconsistent with treatment and other documentation.
2 of our hospitalists are dead set against the CDI program, and sometimes it seems they are being purposefully inconsistent. For example: Hx of CHF, documentation of CHF exacerbation for first 3 days. Orders: multiple doses of IV Lasix or a Bumex gtt, CXR w/cardiomegaly, consistent with CHF, Echo: EF 25%, dilated LV, etc. We query for type of CHF and the response is, no CHF. DC summary says "Volume overload, patient has no history CHF". It can be frustrating.
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
We had those same struggles... We are doing a Documentation Optimization program with our EMR vendor that gives us capabilities to add the query answers to the pt problem lists. The MD then has the ability to see each of the dx on the problem list and note the status of the condition (ruled out, treating with..., resolved, etc.) They will still have the ability not to add a dx to their assessment and plan each day, but it will still prompt the MD's with the entire problem list.
Right now, we ask for them to answer on the query and carry the answer into their progress notes. We will say that happens.. 75% of the time, but our EMR allows those "behaviors!" So until we can get those kinks worked out...Our focus lately: Defendable Records! We provide the MD's with cases we have had to defend against RAC or Insurance denials and let them try to defend the dx based on the documentation! It is really an eye opener to them when they have to defend a case from 3 years ago! Sometimes they just didn't realize what they wrote "conflicted" someone else b/c it was "their opinion." And then the politics! The issues that have nothing to do with our CDI program- but still end up driving us crazy!!! We have been able to ID some of those issues and manage them up for assistance which in turn has helped our program!
Amazing CHF seems to be popping up as an issue lately! We found out that MD's were too afraid of getting 'dinged' under their contract for core measures, so they didn't want to document CHF or even a history of CHF. It really boiled down to the MD's needed education related to the actual CHF measure. They just didn't understanding how the measure worked. The combo codes that lead to CHF as Pdx, the criteria to be included/excluded from a measure, and the fact this measure can be driven at discharge. The MD's thought they couldn't get dinged for not doing the core measures if they (as the attending) didn't document CHF. It is hard to prove that a dialysis pt has just "vol. overload" when the pt is at dry wt, didn't miss HD, noted to be very compliant with HD/meds/diet, and has a know hx of CHF....esp when you treated them with IV lasix and not HD. (Yes, we had several long discussions about this case well after discharge!!!)
Good luck!! Administration backing has definitely been our biggest asset!!!
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens