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Hospitalists Can Be Champions of Clinical Documentation


To improve your hospital’s reimbursements and key indicators, including observed and expected (O/E) mortality ratios, personalize your collaboration with clinical documentation specialists (CDSs). That’s what has worked at two medical centers where hospitalists teamed up with CDSs to improve their hospitals’ claims processes.

At Northwestern Memorial Hospital in Chicago, the hematology/oncology service was selected for a pilot program to focus on improving expected mortality rates. The specialists needed to ensure that coded data sent to state- and hospital-associated databases (as well as payor claims, such as those submitted to Medicare) accurately represented the severity of patients’ conditions upon admission. To do that, they needed buy-in from hospitalists to make their notes as complete as possible.

Instead of writing “AKI-obstructive,” we now write “AKI due to ureteral obstruction from peritoneal carcinomatosis from metastatic gastric cancer.”—Charlotta Weaver, MD, medical director, oncology hospital medicine service, Northwestern Memorial Hospital, clinical instructor, Northwestern University’s Feinberg School of Medicine, Chicago

Hospitalists usually encounter CDSs anonymously, through an electronic query in the electronic health record (EHR). Kristine Green, RN, a CDS, quality leader, and interim manager at Northwestern’s clinical documentation program, approached hospitalist Charlotta Weaver, MD, medical director of the oncology HM service and a clinical instructor at Northwestern University’s Feinberg School of Medicine. Green suggested she shadow Dr. Weaver on rounds.

“We had implemented this technique in a couple of our other service lines, with good results,” Green says. She compared her notes on patient visits with Dr. Weaver’s notes and was able to catch conditions that were being undercoded. They generated a list, now posted in the work room, disseminated via email, and included in the orientation binder, of frequently missed coding diagnoses.

For example, Dr. Weaver explains, “instead of writing ‘AKI-obstructive,’ we now write ‘AKI due to ureteral obstruction from peritoneal carcinomatosis from metastatic gastric cancer.’ ”

Such specificity in physicians’ notes translates to a more accurate level of billing for the hospital and a more accurate reflection of patients’ acuity in comparative databases. With Dr. Weaver paving the way, Green has forged “a nice rapport” with the other hospitalists in the oncology medicine service.

Audiences for Your Notes

CDS and hospitalists might initially view notes differently. Most physicians train in programs where the “primary intent of a note” is to communicate to the rest of the medical team what’s happening with the patient, Dr. Weaver says.

Listen to The Hospitalist's interview with Dr. Tsomides discussing billing and coding improvements available to your HM program.

“When we train, we’re always thinking about communicating with each other,” says Theodore (Ted) Tsomides, MD, PhD, an attending physician on the hospital medicine service at WakeMed Hospital and assistant professor of medicine at the University of North Carolina’s School of Medicine in Raleigh. “But as we get into the system, we realize that there are a lot of eyes on those documents. And whether we think about it or not, those are all our different audiences.”

Once hospitalists develop confidence and comfort on the job, Dr. Tsomides says, they can move on to aligning themselves with the hospital’s interests. Dr. Weaver thinks hospitalists are uniquely positioned to help champion the CDI efforts. “We’re here to improve the mission of the hospital,” she says.

As physician liaison for quality programs, Dr. Tsomides began working on clinical documentation improvement. He became a resource for the department, and then worked to achieve a financial incentive plan for hospital physicians when their documentation improved. He’s also been pushing his institution to make the documentation process easier by using electronic queries, and by introducing residents to the “real world” of clinical documentation in their curriculum. (Click here to listen to more of Dr. Tsomides’ ideas to improve clinical documentation.)

He advises hospitalists meet their clinical documentation specialists face to face. “Once you know there are people who are doing their part, and have a relationship with them, you approach the whole problem differently,” Dr. Tsomides says, “as opposed to [viewing them] as anonymous reviewers breathing down your neck and giving you yet another thing to worry about.”

Gretchen Henkel is a freelance writer based in California.

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