Chart Conundrums: Queries: Moving Beyond Business as Usual to Identify Learning Opportunities
By Clarissa Barnes, MD
For The Record
Vol. 33 No. 3 P. 26
While often said in jest, my dislike of getting queries delivered to my inbox is (at least indirectly) 100% responsible for my work as a physician advisor. Queries were an intrusion in my otherwise organized workflow. It seemed like my only option was to keep answering them for the rest of my career.
However, once I was able to see that queries could be opportunities to improve my documentation not only for that chart but for all future charts, they became impromptu ways to learn. The same philosophy can be applied to the other side of queries. As a physician advisor, it often becomes my responsibility to “remind” physicians to answer their queries. Understanding why someone has trouble is key to helping that individual answer queries.
We can also go beyond just solving problems as they come up and be proactive in finding ways to make it easier to answer the queries in the first place.
A Brief History
How did a dislike of queries lead to a career in which I deal with them all the time? At the time I graduated from residency and started my first clinical job, I had had exactly zero education on documentation. At that point in time, I viewed the medical record as a way to convey information to myself, colleagues, consultants, and other members of the clinical team. While I was probably aware that others might read my notes, it did not occur to me that there would be any issue translating clinical jargon into codable information or that I might not be capturing the diagnoses I thought I was because I was not using the right combination of words.
As a result, like many young physicians, I received queries to clarify diagnoses or to add ones I had overlooked. And, like many young physicians, I was a bit annoyed. Why couldn’t others see what I thought I was so clearly saying?
I endlessly repeated that cycle of documenting, being queried, and clarifying until I realized that I had the ability to make it stop. The next query I received to specify the chronicity of heart failure, I wrote myself a reminder to be more specific and taped it to the side of my computer. Lo and behold, the heart failure queries stopped. I realized that every query was an opportunity to learn, which could lead to them being eliminated altogether.
It was around this time that the hospital was looking for clinical documentation champions to attend an educational series and to share the knowledge they gained. Before I knew it, work in clinical documentation integrity led to work in quality and utilization management and an additional career as a physician advisor.
Tips for Getting Answers
Break down your approach to getting physicians to answer queries similarly to how I broke down my response. Business as usual is working with individual physicians to get them to answer queries just like the standard for physicians is to answer them. However, there are strategies to increase the odds that queries will be answered quickly and appropriately.
How can physicians (and nonphysician clinicians) with a habit of slow response times improve? To get a clue on how best to communicate, it’s important to understand the underlying reasons physicians and other clinicians may delay responses.
The most common issues are the following:
• Inconvenience: In most EMR systems, answering queries is outside the normal workflow. For example, the EMR implemented at my facility requires users to go to an area distinct from where all other documentation resides. Answering queries often requires multiple clicks and loading screens. What may entail one minute of actual work takes infinitely more time when users must interrupt their routine. Also, any tasks outside the normal documentation workflow are easier to forget.
• The guessing game: When queries are sent, the requestor often knows the “right” answer. Sometimes the physician also finds it obvious (“Oh, I forgot to say it was systolic heart failure.”). However, guidelines prohibit requestors from issuing leading queries, which sometimes leads to confusion. Some query frustration results from not understanding what’s even being asked.
• General overwork/burnout: Sometimes it is not even about the query itself. Some physicians are already so overworked that just doing one more thing—such as answering queries—feels taxing.
• Misunderstanding the purpose of queries: For some physicians, there is a disconnect between why queries are important and why their timely response is critical to the hospital’s workflow. If something is not important, it is easy to delay that work. Conveying to physicians how answering queries is critical to patient care and hospital workflow is critical to giving them meaning.
• Pride: This is less common, but sometimes there are a few physicians who believe the purpose of queries is to “correct” their errors. Therefore, any query feels like a scolding and is associated with negative feelings.
In my experience, inconvenience tends to be the largest hurdle to getting queries answered. Because I considered myself to be efficient when rounding and documenting, an unexpected query felt like an intrusion. Once I figured out a workflow to better incorporate queries and a general strategy for decreasing their number, that annoyance dissipated.
Focus on Systemic Solutions
How can query problems be solved? Clinical documentation specialists must adopt the right attitude. This is not as cheesy as it sounds. Physicians who have issues answering queries are not “bad” people who need to be reprimanded. Rather, they most likely are having trouble in one or more of the five areas mentioned previously.
Figure out the cause of the headaches and approach it like a problem that can be solved together. This strategy is likely to garner infinitely better results.
If the issue is workflow, ask the physician advisor to offer a solution or two to better incorporate queries into day-to-day activities. If a physician does not understand the importance of queries, explain how they improve chart accuracy, which leads to exemplary quality metrics, financial metrics, and, most importantly, improved patient care. After all, if it is not clear in the chart, it may not be clear to other members of the care team.
Expect to get quite a bit of mileage out of such cooperative problem-solving. Additionally, there are other ways to identify changes to help improve the query process for everyone, including the following suggestions:
• Involve physicians. Most health systems use documentation templates, which helps make them recognizable to users. Ideally, those templates were created with physician feedback. In a similar vein, ensure the physician advisor and physician documentation champions are at the table when discussions involving how to improve the query process take place.
• Demonstrate how to avoid queries. To avoid multiple, regular queries on the same topic—heart failure, for example—arrange a meeting with the clinician to show the patterns and how to avoid them. Queries do not have to be a nuisance—in fact, they can be learning opportunities.
• Send query completion reminders at ideal times. Standard operating procedure for physicians is to conduct pre-rounds with a morning chart review and then take to the floors to round on patients. Should a physician receive a text or call reminding them about a query during those hours, there is a good chance it will have been forgotten by the time they get around to documenting in the EHR. For clinical documentation specialists, it may be more convenient to check the list of unanswered queries upon arriving at work and then send off reminders. However, the chances of receiving a prompt response increase when reminders are sent late morning or early afternoon following rounds. It is also best to avoid the lunch hour. Physicians may not have a typical lunch break but they do tend to schedule meetings during that timeframe.
• Offer education. This can be written information, videos, or just a conversation. The more education offered, the more physicians will feel comfortable reaching out when they have questions on those “guess what I’m thinking” queries.
• Optimize query efficiency. Ensure IT has optimized the process of viewing, responding to, and signing queries to the best of the EMR’s ability. Hopefully, this is done with HIM’s input.
In an ideal world, documentation would be 100% accurate and 100% on time, making queries obsolete. The next best thing is to establish an efficient query process—one that can help clinicians identify and correct their biggest stumbling blocks to responding to queries.
Queries don’t have to be painful—they can be learning opportunities for both clinicians and nonclinicians alike.
— Clarissa Barnes, MD, is a hospitalist and physician advisor for Avera Health and Avera McKennan Hospital and University Health Center. She is also the vice president for member engagement for the American College of Physician Advisors.