Podcast Episode Transcript: Getting credit for great work: Helping physicians improve documentation

Dr. Gordon Moore: Welcome to the 3M Health Information System’s Inside Angle podcast. This is Dr. Gordon Moore. I’m your host, and today I’m talking with Dr. Eugene Christian, who is the Chief Medical Officer of St. Mary’s Hospital in Richmond, Virginia, part of the Bon Secours Health System. Welcome Dr. Christian.

Dr. Eugene Christian: Thank you, Gordon.

Dr. Moore: Tell me about your work on quality and what got you into this position now. A little bit about your trajectory. Because I understand you are an orthopedist, and here you are working on quality and coding. It just begs the question, how did you get there?

Dr. Christian: Right. I’ve been asked that question quite a bit, actually. Not common for those of us in orthopedics to head in that direction. I actually practiced clinical orthopedics for about 28 years, and some time in 2012 I was approached about taking the Chief Medical Officer job with Carolinas HealthCare System at the Mercy Hospital campus, where I had been working as an orthopedist.

Considering my career over the years, I thought I’m ready for something different. I had been in leadership positions throughout my career. Not only in orthopedics, but in medical staff and administration, and on the quality improvement committees that I’ve been part of. I thought maybe this was an opportunity for me to do something different: medicine that didn’t involve one patient at a time. It was a chance for me to work on improvement that would affect not one person, but thousands of people, and help improve the overall quality of the care we provide.

After some consideration about jumping over the fence, as we say, to the administrative world, I took that position in March 2012, and it was really a cold turkey move for me. I went from full-time orthopedic surgery to full-time hospital administration, so I gave up clinical practice completely at that point. It was tough decision, but I felt I was ready for something else, and that made a lot of sense.

Dr. Moore: At Carolinas, which is now Atrium Health, there is an amazing amount of work around quality improvement. An amazing amount of organization. I understand that you were part of that and looking for, within the context of orthopedics and spine surgery, opportunities for improvement in healthcare delivery that would improve patient outcomes, as well as improve cost savings. Can you tell me a little bit about that work?

Dr. Christian: The quality improvement work, for Chief Medical Officers, is probably one of the major parts of our job. The first part of the job description is we improve the quality and safety of the patients that we take care of in the acute care setting. A lot of the work is about process improvement. One of the most important aspects of that work I discovered after I’d really gotten into it and started looking at how do we do improvement—how we change clinicians as far as doing best practice and clinical transformation—a lot of it depends on how you’re measured. If you’re not measured properly, then that plays into what your improvement work may or may not entail.

For instance, if your length of stay looks like it’s 25 percent above everyone else’s, are we not doing things properly on the clinical side? Are our clinical pathways incorrect? Are our physicians not following best practice? But when you dig into it, oftentimes what you find out is—when you’re being compared to others, you find that, well, our patients aren’t as sick as everyone else’s, but we feel like they are.

That’s when I discovered the importance of documentation. Because really, when you start looking at quality metrics, you look at how everything is measured. It all comes down to what’s in the medical record and how it’s coded. Coding is everything. And so I found that out fairly quickly as I dug into what our issues were at Mercy when I first took the position. I quickly discovered if we improved documentation, our expected numbers for instance for readmissions, mortality—we were now getting credit that. So if your “observed” to “expected” wants to improve, you want to make sure that your expected is correctly measured. We when we started digging into some of this work. I found that we had a lot of opportunity there. In many cases, some of our physicians found that they actually were doing great work. They just weren’t getting credit for it, because they weren’t documenting properly. That’s when I became a disciple, so to speak, of the whole documentation world.

Dr. Moore: That’s one of those areas where I hear a lot about clinician and physician frustration and practice in the burden of documentation and the detail and everything that has to go into the note. I’ve had one guy at a meeting say, “I can sit down” (and he’s a physician)…”I can sit down in a medical lounge and I can have a conversation with somebody about congestive heart failure and everybody knows what I’m talking about. There’s no ambiguity. Yet when I document, I have to get into all this detail and it’s not clinically relevant, and it’s just absurd.” What do you think about that?

Dr. Christian: You know, it’s real. Physicians, we speak more in general clinical terms. We don’t really speak in diagnostic terminology. Unfortunately, the coding world really has to live in diagnostic terminology, so we have to be very specific. You’re right. If I’m sitting in the lounge and I’m talking to my colleagues, and I’m saying to my nephrologist, “I’ve got a patient that I think’s got some renal failure. It looks like the creatinine’s going up. Could you come see him?” That’s what I would say. But in the chart, what I really should have said, “I’ve got a patient with acute kidney injury and acute renal failure that needs to be looked at,” and actually document that properly as what it is. We don’t talk the same way we need to document, and I think that’s where the disconnect is for physicians.

Dr. Moore: That rings true to me. As I think about, in a conversation, we can use shorthand. And the shorthand can communicate a lot. But if I have to talk to a cardiothoracic surgeon, and they’re going to go in there and do a procedure, they’re going to want a great deal of specificity and information about the patient. It’s that kind of specificity that has to be represented in the way we record information about a person so that there is no ambiguity.

When we have a written record, it’s a static thing, and there’s no chance of dialogue going back and forth—the, okay, I need to know a little bit more if I’m going to go in there and do something about it. If we only have a vague representation, then the interpretation can be broad, and therefore, we won’t know was something done appropriately or not. Is this a quality problem? Is this just a lack of documentation? Does that ring true?

Dr. Christian: Absolutely. That was what I found out when I started looking into it, because there are places in our facility where we actually were doing really great clinical work, but our metrics didn’t look good. Everyone was sort of scratching their heads, and the clinicians were like, I’m doing everything by best practice. I don’t understand it. When we started looking into the documentation part, and really teasing it out, we saw some significant opportunities that, really, just a few changes in terms and making sure that that was in the medical record. The metrics changed dramatically.

As I started to talk to physicians about that, that was really the message I was carrying: You need to take credit for what you do. Get the credit you deserve for the acuity of the illness of the patients you care for. Because every physician will say, when they’re being compared to other physicians on quality metrics, the first thing most of them will say, well my patients are sicker. Well, great. Just prove it.

The only way you can prove it is to document properly just what their real conditions are. If you do that, and you’re good at that, then you will actually get credit for it. In many cases, you’ll see improvement [in performance measures]. There are some physicians that may not see that much dramatic improvement, because they’re already good at it, but I can tell you that when I started the work, most were not.

Dr. Moore: I’m thinking again about a colleague sitting there and saying, “This is all just about the money. You’re just trying to squeeze dollars out of this, and this is really not about patient care.” I guess we really are touching on that, because you’re describing this as, yes, it can drive revenue, but it really is a lot about quality and how we understand people. How have you responded to that, it’s all about the money kind of push back?

Dr. Christian: Unfortunately, in years past, that’s what physicians heard. When they would go to utilization management meetings, what was always thrown up was, here’s our dollars that we haven’t billed for because we haven’t documented properly, or the queries weren’t answered. So the message was always about the billings for the hospital. Honestly, at some point, physicians grow weary of hearing that. It’s not a message that they can really latch on to over time, particularly if you’re an independent physician.

If you’re not employed by the hospital and you’re not getting your paycheck from them, they don’t care that much. They’re going to make sure their documentation in their op note for a surgeon is proper. They’re going to make sure all of that is properly done on their end, because it means something for their reimbursement. But when you talk the hospital side, you’re talking about some third party, it doesn’t really ring very true.

But when you start to talk about quality metrics, and you talk about value-based purchasing, which is the new world we’re in, and everyone’s being measured including the physicians, on an individual basis, now it matters. There are dollars attached to it for physicians, and there’s penalties that can ensue if you don’t meet those quality metrics. So that’s become a different conversation now. When we talk to physicians about that, that’s what we talk about. We don’t talk about billings to the hospital. We talk about your quality metrics. Take credit for what you get. Are there dollars associated with it in value-based purchasing? You bet there are. And can they affect you individually? Yeah. They don’t individually affect many physicians personally yet, but they will. That day is coming, so physicians are beginning to realize that. They’re starting to marry up the quality conversation with the dollars that are tied to that quality.

But when I first started talking to physicians, I just wanted to take the dollars out of it. I wanted it to be about, this is what the quality metrics look like for you, doctor. They’re not as good as your peer group, so let’s find out why. If it’s documentation, let me help you with that. Because you’re a good physician. You get good results. But you can’t show it, so let’s show it. That rings true.

Dr. Moore: How do things go back in North Carolina when you were doing this kind of work? What sort of results did you get?

Dr. Christian: As it turned out, when we first started talking about this, we didn’t really have, other than the individual hospital CDMPs1 and coders who would reach out to physicians individually with queries, the education program really didn’t exist. What really drove us to start talking to physicians on the education piece was the whole conversion to ICD-10. Because everybody was afraid. No one understood it. It’s really broadened. You need to educate.

So as we started to talk about how do we educate the ICD-10, the conversation quickly turned to, well, it’s not just about the ICD-10 piece. Let’s educate about documentation in general. At Carolinas, we didn’t really have a centralized repository for the source of truth, so to speak, so we created what we called the Documentation Excellence Committee. For us in our primary enterprise, it was a system committee.

That was the committee that had physician members from the different specialties. I chaired it as we brought it together. And we had CDMP. We had coders at the table. We had everybody at the table that could talk through what was needed and how we could document better. That committee started as a place to, let’s just teach ICD-10, and it quickly morphed over time into,  hey let’s start looking at all the quality metrics that are tied to value-based purchasing. Let’s look at mortality. Let’s look at readmissions. Let’s see how this documentation piece corresponds to those quality metrics. We quickly found that not only was there opportunity there, but there were some really quick fixes that we could provide. We started educating physicians by group and by individual. As we started to do the work, we asked our coders and CDMP staff, can we get more real-time with our docs? Rather than send them a query after the patient’s been discharged and they have to go back into a chart after the fact, which physicians always hated to do, can we do concurrent coding.

We created some teams in the hospitals that were up on the floors where we saw the most opportunity. We had coders and CDMP nurses on the floors with the physicians, pretty much elbow-to-elbow. They started having those conversations with them while the patient was still in the hospital. That made a dramatic difference. Physicians began to understand how important it was because we had people there with them while that patient was still in the hospital to help them with the coding piece. It helped also because they could ask questions real time.

It really started out as, how do we educate better, and then it became, how do we actually improve the entire process by doing this better.

Dr. Moore: Was it critical to have the person there elbow-to-elbow? I’m just thinking about the cost of staffing that.

Dr. Christian: It made a difference. In the places we did it, and we didn’t do it on every unit. We looked at our opportunities in the documentation, and we saw some in cardiology, we saw some in general surgery, neurosurgery—so we specifically targeted those units and those physicians. It was targeted work. Places where we knew we needed to make a difference. Some of our general medicine units, we saw an opportunity with our hospitalists. But it wasn’t every unit had it. It was, where’s our opportunity? Where do we need to educate the most, and target those areas?

Then we had generalized education that we had rolled out to the physicians that we made available to them. Websites—education they could get on the Internet. As physicians begin to understand the importance of that, we had more and more physicians actually partake of the education process.

Dr. Moore: Is this something that you go through a learning curve and you get people up to speed, and then you can back it off and you’re pretty much good to go?

Dr. Christian: You can. Again, you look at your different specialties where you find opportunity. Once you get the majority of the physicians understanding it, then you can focus your efforts on other places where you think you need to do the work. But since we had a documentation excellence committee that really watched and observed and measured the effects of this on an ongoing basis, we were always able to look back and see, are we maintaining that improvement that we had gotten. If we saw a slip, we could certainly go back and talk with the physician group again and re-engage them.

But it was interesting. Once the physicians knew what to do and learned from it, we really didn’t have to go back that often. One of the measures of success for us was that we were measuring not how many queries were responded to and what the percentage of response rates were. It was how many less queries did we send out over time. Because if we were sending less out, we knew that the physicians were then documenting properly. We could tell that they were improving. That was our measure of success. Are we sending our fewer queries than we used to? That was our goal.

In years past, CDMP’s measure of success was how many queries did they send, how many percent responses did they get, how many agreements did they get. That’s been a metric that CDMP and coding’s been looking at for many years. But our goal was to actually decrease the amount of those that were coming out.

Dr. Moore: Yeah. I mean, I got to figure, there I am working on the floors, and if I’ve got somebody tapping my shoulder or I’m getting messages when I’m logging into the EMR, I should quickly learn that if I’m going to document this thing, I want that level of specificity or I’m going to get this inquiry coming at me. So let me go ahead and take care of that now up front rather than wait for the query to come in the back end. That should extinguish it, just as you’re saying. Did you track that, and that did actually bear out over time?

Dr. Christian: It absolutely did. I can tell you from my own personal experience, again the orthopedic surgeon in the room. When I started getting queries about, “doctor we saw that you transfused two units of blood in your post-op total hip patient. Did not see anywhere where you had indicated the reason for that. Well, bygolly, it was blood-loss anemia. All I had to do was write that.

But I never wrote it. I just said, patient hemoglobin is 8, or 7.5. I’m going to transfuse two units. What I needed to say was the patient has acute blood-loss anemia with a hemoglobin of 7.5. I’m going to transfuse two units. After I got a few queries, finally I realized, gee, if I just say that every time I do it, I won’t get a query anymore. And bygolly, that worked like a charm. So that type of education really does make a difference.

Dr. Moore: Were there any surprises for you when you were rolling this out?

Dr. Christian: Yes. One of the good surprises was that when we started explaining this to physician groups and certain specialties where the opportunities were, I really was surprised that the majority of physicians really embraced it. Once they understood what it meant for them from a personal perspective, like here’s my quality metrics. I want to be measured properly. And also from the standpoint it really did help their patients because the patients now had accurate documentation of what occurred with the episode of care that they had.

That surprised me. I expected more resistance. I had pockets of that, but I didn’t have the large resistors that I thought would take me a year to get over. Some of them were harder than others, but it was a matter of months, not years, to get there. I was surprised that people were beginning to understand that better. Once we changed how we messaged it, it made all the difference in the world.

Dr. Moore: And that change being that it’s about quality?

Dr. Christian: Exactly. It was all about quality metrics. We just stopped talking about hospital billing. Just stopped talking about it.

Dr. Moore: Now you’re Chief Medical Officer at St. Mary’s Hospital, and part of the Bon Secours system in Richmond, Virginia. Tell me about that role, and what you’re engaged in at this point.

Dr. Christian: I moved on to a similar role as the Chief Medical Officer at St. Mary’s of Bon Secours. The role’s very similar in looking at quality improvement, quality metrics, length of stay. Efficiency and patient flow are all parts of the opportunities every hospital has. Ours particularly, as we’re a tertiary care facility for Bon Secours Virginia, so we get a lot of referrals, so we’re very busy. We have a lot of high capacity, so that kind of work is very important for us.

When I came here, I found very similar opportunities as far as the documentation improvement when. Every hospital system has a CDMP. They’ve got coders. There were certainly some struggles here getting physicians to understand that, because again the message had always been the dollars billed for the hospital versus the quality metrics.

So I started to do some of the same work here that I’d done at Carolinas. I sort of repeated the same type of process we had, and found that resonated a lot with the physicians once I started talking in those terms here. Same types of opportunity, and I approached it the same way—here’s the quality metrics you’re going to get credit for. Take credit for how sick your patients are.

Dr. Moore: How’s the roll out there? Is it matching what you’d experienced before?

Dr. Christian: I would say it’s not as robust, just because I’ve had to recreate the structure for that, which we’ve been working on for the past year. I’ve been in this role now a year. We’re beginning to catch up to it. Because when I did this work at Carolinas, I had been in that role, it was really about a year and a half to two years in, as we were doing those improvements, that we really started to see the difference. So I would say at about a year here, we’re starting to see some change. It takes some time to really get that message out and start getting everyone on board with it. Even some of the administration folks that were here needed to understand that message, as well.

I think we’re on a pretty good trajectory now to start making those improvements. A lot of this has to do too with how physicians have to answer the query process. In the electronic medical record, my experience with the way most EMRs do it on their own is it’s done through a message center type system. It’s rather clunky. Physicians have to go into that, open it up, and they have to go into the record, make a change.

Once we started cleaning that up at Carolinas, and I’m in the process of cleaning that up here as well, and made it easy for the physicians to answer those queries and get them in the record, we saw even faster improvement. It’s really multi-tiered. It’s understanding what you need to do, and then making it easy for the physicians to do the right thing.

Dr. Moore: I’ve heard people describe programs that add clicks to their day as being painful, so you’re going after approaches that would reduce that.

Dr. Christian: Absolutely.

Dr. Moore: Tell me about Lieutenant Christian’s Little Blue Book.

Dr. Christian: [Laughs] Okay. So you found it. Back in my Navy days, I had been in part of the Navy health profession scholarship program, and went through med school there. When I got out of medical school, I did an internship at the naval hospital in Portsmouth, Virginia, and I was going to be pursuing orthopedics. The way it worked there was after a year of internship, you were assigned as the General Medical Officer onboard a ship. I was assigned to the USS Nashville, LPD 13. Lucky 13. We were a Marine amphibious transport ship.

When I got to the ship, I had the usual turnover with the other physician that was there, which is usually an afternoon of, here’s where your state room is, here’s where sick bay is, and this is where you go for morning quarters. Good luck. Have a nice year. That was my turnover. So I got to the ship and had to learn by doing. Fortunately I had some good enlisted folks onboard that could help me through it.

About halfway through that deployment, I realized it’d be nice if somebody would have something written down, like a little manual of how do you do shipboard medicine. At the time, it didn’t really exist. So I decided that would be my project while I was deployed. You know, you’re out to sea for six months at a time, so you’re taking care of the crew, and you’ve got some time to do some reading and studying and some writing. I decided that I would put together this manual.

That was the genesis of it. It was just not having anything to go to in order to help me do my job. After that year, I had taken my notes, put it together. My lovely and charming wife helped type it up for me, and submitted it to the Navy. I had a captain, Captain Cowen, my coauthor, who sponsored it at the Bureau of Navy Medicine at the time, and took it up the chain of command for me. That became Lieutenant Christian’s Little Blue Book.

Dr. Moore: And it’s still out there.

Dr. Christian: It is still out there. It’s interesting, because my middle son, Matthew, just finished his internship at the naval hospital in San Diego, so he’s going to be a Navy physician as well. Medicine’s changed a little since 1981, right? So that book actually has gone through a couple of edits. It’s gotten some revisions put in because medicine’s changed. Some of the Navy regulations have changed. My son is now onboard a ship and deployed and has that book. His job is to do edition number three. It’s going to be kind of cool that my middle son’s going to be the editor for the third revision. I’m happy and proud about that for him, and it’s sort of a neat legacy left over from my days onboard.

Dr. Moore: Dr. Christian, that is a terrific story. It’s no surprise to me that your interest in improving process and communication started early, and you’ve maintained it through your career. Thank you so much for your time today.

Dr. Christian: Thank you for having me. It’s been a pleasure, Gordon.

Dr. Moore: For Inside Angle, this is Gordon Moore. You can find more podcast episodes at www.3MHISInsideAngle.com.

1CDMP – Clinical Documentation Management Program

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