QUERY WEARY DOCS?
P. Roger DeVersa, MD CPE MBA FHM
CCS CDIP
Holy Grail of CDI of CDI
How to Engage
Physicians to Respond
To Queries
Objectives
• List potential reasons queries go unanswered
• List strategies to improve query response rates
• Explore communication differences that may
exist between physicians and nurses
• Describe methods CDI professionals may use
to potentially influence physician behavior
Audience Benefits
• Learn strategies to improve query
response rates
• Explore communication differences that
may exist between physicians and nurses
• Review steps of effective communication
Just ANSWER the Query!
• “I don’t know why they can’t just answer
the query!”
• “Why can’t you just write it this way?”
• “Why is he being so hard headed?”
• “Does she not see that this is going to
cost the hospital money?”
What does she want from me?
• “Just tell me what to write, and I’ll write it”
• “Don’t tell me how to practice medicine”
• “I’ve been doing this a lot longer than you
have”
• “You’re just trying to get more money for
the hospital, this has nothing to do with
quality care”
• “What about the new CT Scanner the
hospital promised me?”
Lack of Understanding
• Physicians may not understand the goal of
the query process.
• CMS uses the English language in a
manner that could be interpreted by some
as a foreign language.
– Urosepsis is not the same as UTI and Sepsis
in the CMS language called English, but it is
the same entity in the physician language
called English.
CMS-LISH
CMS - ENGLISH
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Hyponatremia or abnormal lab value
Acute renal failure or acute kidney disease
Myocardial infarction or NSTEMI
Others?
Unintended Consequences
• Many physicians do not realize that the
words they utilize in the medical records
are not sufficiently detailed to capture the
true nature of the patient’s illness when
viewed through the lens of the coder’s
glasses.
Physicians typically document for the
benefit of physicians and care providers,
not coders.
Competing Responsibilities
• Physicians have multiple competing
responsibilities that vie for their time and
they may perceive a query as a low priority
task
• “pt with sodium level 110, what is the
diagnosis”
Educate the Docs
• Typically they can be educated
• Typically they understand complex tasks
• Typically they require/desire to understand
the reason or logic supporting the initiative
• Typically respond to “report cards” or
comparative reporting
• Low hanging fruit approach
Align Goals
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Employed physicians
Contracted physicians
“Private” physicians
Physicians in training
Medical specialties
Surgical specialties
Physician Feedback
• CDI process impact on
– Case mix index
– Financials
– Length of stay validation/support
– Expected versus actual mortality for each
provider
Administrative Support
• Top down support
• Have a CDI department mission statement
and live it
• Be consistent with your mission statement
– All charts, including self-pay patients
• Be honest with the doctors
– “to improve specificity”
– “we just need to know if its severe or nonprotein calorie malnutrition”
That’s What I Heard
That’s Not What I Said
Communication is HARD!
• Complex skill that requires many steps
• Send a message
• Use a method/language both parties
understand
• Other party hears the message
• Other party understands the message
• Feedback given to the sender of the
message
Barriers to Effective
Communication
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Filtering (all mothers know this one)
Selective perception (all husbands…)
Information Overload
Emotions
Language
Gender differences
Physician / Nurse differences (does it
exist?)
Physician Education
• Physicians are trained to focus on the one
patient in front of them and to do what that
patient needs – blinded to all others regardless of what resources are available
or how they are to be obtained
Nurse Education
• Nurses are trained to care for groups of
patients with the resources that are
available to them at that time
• “If you can’t do anything about a problem
– it can’t be a nursing diagnosis”
Perceptions
• Early career physicians are not fully aware
of the assessment skills and knowledge
resource of highly experienced nurses
• Early career nurses may not be fully aware
of the limitations of the assessment skills
and knowledge level of the early career
physicians.
Operationalize
Power of Persuasion
• Stay goal oriented
– Achieving your metrics is more important than
winning an argument or being ‘right’
• Develop a team strategy
• Deploy strategy consistently
– Requires buy-in from all members of CDI
team
• Involve the physicians in the decisions as
able
Persuasion
• You’re attempting to influence behaviors
or attitudes towards CDI
• Develop a Sales Pitch
• 5 Minute elevator talk
• Realize that you will influence behavior by
appealing to logic/reason in some doctors
and habit/emotions in others
– Ex. Dr. DeVersa and banned abbreviations
How to Persuade
• Make a connection
– Professional athletes and commercials
– Coca Cola and polar bears
• Reciprocity
– You do something nice for me, so I feel obligated
to do something nice for you.
How to Persuade
• Liking
– People say ‘yes’ to people that they like. A
person can more easily influence someone
who ‘likes’ them
• Authority
– We have a tendency to believe someone that
we think is an expert
Questions?
Question
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