Clinical Documentation Integrity, previously referred to as Clinical Documentation Improvement, has been a strong passion of mine for the past twenty-seven years, predating the recognition of CDI as a profession. I am always advocating for and will continue to advocate for a radical transformational change in current CDI processes that do not lend themselves to true physician engagement as willing active participants. Active physician engagement beyond that represented by simply answering queries is necessary for an effective CDI program that noticeably moves the needle in clinical documentation with sustainability. There is a definite natural resistance to change within the profession given the comfort level of the status quo. Marked changes in CDI structure and processes are not always easy with current forces in the industry content with present CDI processes. The CDI associations and CDI consulting companies are happy with the current CDI situation since both are continuing to find the current status to be quite profitable. After all, why change if money is being made with software and consulting engagements.

In regards to CDI transformation, I recently LinkedIn with a Business Development professional representing a unique clinical documentation software solution. We conversed over LinkedIn, looked at the firm’s website and was intrigued by the informational content appearing on the website to the point I requested a demonstration to learn firsthand the solution’s functionality and capabilities. During the demonstration of the physician documentation solution, asking pertinent questions, seeking clarification, and reflecting on the information gained, it is evident this software’s capabilities and focus upon truly assisting physicians document and chart within the EHR relegates CDI queries irrelevant and not needed. The software streamlines the physician’s ability to capture the formulation of the Assessment and Plan of Care reflecting their clinical judgement, medical decision making, thought processes and supportive clinical facts and clinical information leading to the diagnoses of record with appropriate clinical specificity. One my physician colleagues who is still practicing medicine this is the Holy Grail to accurate and complete physician documentation, relieving him and his fellow physicians of the monkey on their back, that is repetitive queries. The software utilizes Artificial Intelligence to scour the record to ensure no diagnosis is missed, helps physicians spend less time in the EHR, and improves the hospital’s bottom line while alleviating compliance and financial risks. No, this is not an advertisement for this physician documentation solution. Why am I providing you the reader with this information? Allow me to explain and outline below.

The Danger is Real Right Now!

My contention has always been that at some point Artificial Intelligence and other sophisticated IT applications adopted to the EHR would eventually replace manual chart review by Clinical Documentation Integrity Specialists. There presently exists other documentation software solutions that purport to enhance CDI productivity by identifying and prioritizing cases with the highest propensity for documentation integrity improvement, i.e., reimbursement improvement through additional CC/MCC capture. In addition, there exists other software applications that “Nudge” physicians through Computer Assisted Documentation that prompts the physician to document “missed diagnoses” based upon available information in the chart. These offerings primarily focus upon diagnoses capture that impact reimbursement or quality measures in some form or fashion. Coupling these software offerings with the CDI query process increases administrative burden of physicians by taking invaluable time away from direct patient care. Now that there is a documentation solution powered by Artificial Intelligence directed technology that automates clinical diagnoses with supporting documentation that populates into the chart where the physician can either accept, amend, or decline the suggested diagnoses in real time with minimal interruption of the physician, the question remains how does this technology impact the CDI profession? Well, in participating with a client demo for this advanced documentation technology, that very question or concern surfaced. There was unequivocal push back from the CDI Director with reluctance to embrace a technology that not only enhances patient care but also produces notes that are complete and evidence-backed so they can be audited and easily read with no note bloat for payers and physicians to contend with. Note bloat significantly waters down the medical record and the patient story, often times containing untimely and outdated information. My response to the CDI Director pointed out the physician’s desire to provide high quality care, interest in spending less time documenting in the EHR with less administrative burden, desire for less repetitive reactive reactionary queries by CDI and coding to contend with, and interest in easily assimilating all data available in the management of the patient to provide fully informed patient centered coordinated care. The real sticking point obviously was the potential displacement of the CDI staffers. This is where I was able to interject a vision of CDI as mentors, guides, and facilitators of complete and accurate documentation to physicians.

Metamorphosing Into a Crucial Role

A practicing hospitalist colleague in conversation with my experience in the scenario as described above really summarized the situation nicely, the CDI profession must address the necessity to step up to the plate and “Metamorphosize” into a new role, mirroring my assertion that CDI needs to evolve with the times. Reviewing records for CCs/MCCs can now be effectively captured and reported using the various physician documentation solutions available from different vendors. The software I had the privilege of seeing and evaluating provides testament to the need for the CDI profession to embrace transformational change in current CDI processes. These processes have reached their maximum shelf life, especially with the advent of AI backed physician documentation improvement technology with increasing functionality and capabilities to drive real meaningful, measurable, sustainable improvement in physician documentation that is geared towards and embraced by physicians.

Several of my practicing hospitalist physician colleagues have raised an interesting valid point that every CDI professional should take to heart- If the CDI profession, both individually and collectively, does not commit to metamorphosing into the new role of collaborator and facilitator of good physician documentation that best communicates the patient care utilizing what I have coined the “8W’s” approach to documentation, the profession will experience a slow downward death and ultimate extinction. If you think about it logically and realistically, the CDI profession cannot improve the physician’s documentation, instead only the physician can improve his/her documentation. A deeply entrenched misnomer that currently exists is that documentation of a diagnosis by the physician through the query process constitutes actual clinical documentation improvement/integrity. Typical volumes of payer clinical validation and medical necessity denials as well as level ofc are and DRG downgrades further gives credence and support to the fact actual clinical documentation improvement has not materialized despite the efforts of clinical documentation improvement specialists. Current CDI processes were not designed nor intended to achieve any meaningful improvement in physician documentation; instead, they were designed and intended to capture additional reimbursement through capture of diagnoses such as sepsis and secondary diagnoses such as encephalopathy which often are refuted by the payers. Advanced physician documentation utilizing Artificial Intelligence and Natural Language Processing presents the opportunity for the CDI profession to advance and become an integral part of the revenue cycle through collaboration and team building, all a prerequisite for achieving notable meaningful clinical documentation integrity fundamental to ongoing hospital financial viability.

“The New CDI” Profession

What Direction should the CDI profession be headed and what steps should the CDI profession take to position themselves as facilitators, guides, mentors, and subject matter experts to physicians in their achievement of solid and complete documentation, treating the medical record as a communication tool versus reimbursement tool. The first step in this journey to role-based CDI versus today’s model of task based querying farming CDI is to equip ourselves with the skill sets, core competencies, knowledgebase, and confidence in standards of documentation. These standards as defined by Medicare serve as the basis for working with physicians as constituents and colleagues, furthering the ability to capture and reflect quality outcomes-based patient centered cost effective patient care achieved in the management of the patient with documentation in the record. This lack of focus and attention within this realm explains why CDI has failed to achieve virtually little if any clinical documentation integrity. The profession has been taking the wrong approach to clinical documentation integrity, misinformed by industry consultants pushing their consulting engagements as well as their software. In my next article I will provide a detailed roadmap of how a forward-thinking CDI professional can jump start his/her career by acquiring the requisite skills and knowledge in best practices standards and principles of documentation, positioning him/her to complement the CDI technology currently available to drive a holistic approach to physician documentation improvement and integrity driving financial performance of the hospital we are employed by.

With the right CDI approach, we can be true financial saviors for our hospitals in these challenging financial times with the pandemic over the last two years.