Challenges of Educating Doctors on Documentation

By Erica Remer, MD, CCDS

Editor’s note: In response to a call for blog articles from the ACPA blogmaster Dr. Juliet Ugarte Hopkins, Dr. Erica Remer submitted this list of issues she faces when educating doctors and how to overcome them.

1. Time constraints

It is getting increasingly hard for providers to carve out time to do what they consider “non-essential” activities. My approach to this problem is:

  • Hook them so they want to learn more. I had been warned that the surgeons were going to bolt out of an evening educational meeting after fifteen minutes. They became so engaged that they stayed for the entire 90 minute time and beyond, asking questions. It was because they thought what I had to say was pertinent to their practice and I made it interesting.
  • Teach them where they are. I used to attend the surgical M&M conference and give the documentation/coding wisdom after their attendings had reamed them out for the medical incompetence (kidding!). Elbow rounds is a great way to educate individuals as they practice. If you partner with a CDIS, you can close queries and teach providers to prevent future ones.
  • Send them feedback emails that they can read on their schedule.
  • Help the EHR help them. Get IT involved and make them compliant, functional macros and templates that work for them. They will be grateful that you freed up some time for them, and you can call in a favor in the future.

2. Ignorance

Many providers haven’t the faintest idea what a case mix index, comorbid condition or complication, or DRG is. They have no idea why what they documented doesn’t support medical necessity. They think that saying, “elevated creatinine. Will trend.” translates to “acute kidney injury.”

  • Set the stage so they understand the WHY. Why is it important to document precisely? How does it affect my statistics, quality metrics? Why can’t “↑K+” be translated as “hyperkalemia?”

I show them an algebra problem and ask them why don’t they get full credit if they tell me the answer is 3. They figure out that you have to show your work. Then I ask, “What happens if you are my ADD kid and you show all your work, but never tell me the answer is 3? Does he get full credit?” Of course, the answer is no. I nod and tell them they love showing their work, but forget to tell me the punchline, that the answer is 3.

Hyperkalemia is a good example. I ask them, “Is a potassium of 6.8 hyperkalemia?” Some of them shake their heads yes, some no, and some smarty-pants (like Juliet) always says, “it depends.” I then posit normal renal function and on no hyperkalemic meds, grossly hemolyzed specimen. That’s why it takes clinical judgment to determine a diagnosis.

  • Be selective. They don’t have to learn every single condition and there are no magic buzz words, but there are diagnoses which are more relevant to a provider’s practice than other ones. Pick out a few important ones and expect that this will be a marathon, not a sprint. You will have the opportunity to teach them again in the future.
  • Introduce the CDI concept/team to the providers. They can pick up where your education left off and reinforce concepts. Have providers understand why the query process benefits them and how it is critical to answer every time, in a timely fashion.

3. Resistance

There are certain service lines which are more resistant than others (think surgeons vs. hospitalists). It may take time to overcome resistance, but you must persevere.

  • Determine what is important to them. Have they been unfavorably compared with a competing organization in some quality ranking? Does it look like they have unnecessary deaths or PSIs? Has the administration told them they need to cinch up their belt because their reimbursement is not what it is supposed to be? Let them know you can help.
  • Know your stuff. Once they see you understand their perspective and that you know what you are talking about, they will be more receptive.
  • My experience is that once you address their ignorance, it often overcomes resistance too.
  • Catch them early. If you have residents or APPs, get them on board. If the attendings resist, it is often superfluous!
  • Find the tipping point. Find the most influential providers on the medical staff or in the service line and recruit them to be allies or champions.

Providers really want to do the right thing for their patients, themselves, and their institutions. Make them understand that you are their ally, and you want to help them do best practice. Documentation is first and foremost for clinical communication, but there are lots of folks who read what they write. If they accept that you want to help them get credit for taking care of sick and complex patients, they will be receptive, interested, and engaged.