Effective Clinical Documentation Integrity Processes

Mechanics of Chart Review Process

Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facilitates and supports achievement of measurable meaningful improvement in physician documentation that best serve’s the patient’s and all relevant healthcare stakeholder’s needs for accurate and complete communication of patient care. Referring to proactivity, I subscribe to the notion of opening and reviewing a medical record at time of admission or as close to the hospital entry point as feasibly possible. Today’ CDI process of retrospectively reviewing a record for sake of identifying clinical clues warranting a query clarification simply will not suffice with current heightened need for more complete and consistently concise documentation dictated by present adoption of transformative healthcare delivery models. The underlying principles of CDI that we must incorporate into our regular thought processes include assisting physicians adhere to the Hippocratic Oath:

• “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

The following point that appears on the High Value Practice Academic Alliance website outlining the organization’s Founding Principles is directly relevant and plays into the underlying role of a clinical documentation integrity specialists:

1. Medicine is a public trust, and to maintain the trust that the public places in physicians and other health care workers, medical providers have a responsibility to improve value in health care (HVPAA Founding Principles)

So how does CDI as a profession both individually and collectively take the initiative to assist physicians in improve actual value in health care and demonstrate keen financial stewardship to the patient? Rather than focusing upon the endpoint of reimbursement and case-mix, we should be focusing upon advocating for, promoting and achieving more effective documentation by working closely with physician’s as constituents, engaging them as willing participants. This can be accomplished and furthered through recognition of the immediate need to alter our approach to chart review consisting primarily of “after the fact” knee jerk transactional mentality looking for additional diagnoses reporting or clinical specificity. I am certainly not downplaying the importance of complete and accurate diagnoses reporting for reimbursement purposes. After all, without positive net patient revenue and positive cash flow there simply is no hospital mission. The first step in any chart review process is paramount to supporting direct patient care. Equally important is the ancillary roles that play into healthcare delivery as well as aligning and integrating closely with revenue cycle activities is to secure clear, concise, consistent and contextually correct telling and describing of the patient story right from the beginning in the Emergency Department. I liken the concept of solid documentation right from the start at the time of admission and decision to hospitalize to a baseball game. Rather than attempt to be a designated hitter and score a home run while striking out often, a better approach to winning a baseball game is getting on base where upcoming batters can drive more runs through bringing of players around the bases to home plate. The same can be applied to CDI initiatives. A better approach to CDI is getting to first base, that is assisting the physician with being able to communicate the true patient story accurately telling depicting, reflecting, reporting and representing the patient’s clinical picture warranting hospital level of care. This means the physician being able to communicate the patient story in a clear concise fashion outlining the clinical facts, clinical information and context of what was wrong with the patient, what did it look like and how did it manifest. An accurate clinical story furthered by more effective documentation, not more documentation that we see today with note bloat and convoluted information, is germane to establishment of medical necessity and the ability of case management and utilization review to guide physicians in the most clinically appropriate level of care. Fundamental to physicians adhering to the Hippocratic Oath, being strong financial stewards to the patient and practicing cost effective value-based care is effective communication of patient care reflective of the right care at the right time for the right reason in the right venue with the right documentation with the right clinical judgment and medical decision making with the right rationale congruent plan of care.

My philosophy and personal approach to chart review encompasses William’s Osler reference to the medical record as a means and instrument for physicians as part of patient care to observe, record, tabulate and communicate. William Osler was the Father of Modern Medicine, one of the founders to the first “on-the-job” residency training program, John Hopkins Medical School, and was certainly way ahead of his time regarding physician training. Thinking of the medical record primarily as a communication tool for physicians furthers my ability to track and understand the physician’s thought processes, observations, tabulations, interpretations of clinical information and diagnostic results correlating with definitive and provision diagnoses in the assessment, and plan of care congruent and rationale with the assessment. The next step is overlaying an understanding of the medical record as an Evaluation and Management tool whereby the physician records the exchange of clinically reasonable and necessary information between the physician, the patient and pertinent others and uses this information in the clinical management of the patient. Viewing the record in this organized efficient manner, I can identify potential documentation insufficiencies and gaps in documentation detracting from accurate reflection and reporting of the patient’s true clinical picture and story, documentation essential to unequivocally substantiate the need for hospital level of care- whether observation versus inpatient. This is the first step to reaching first base as I described above, serving as a strong foundation for now identifying missing and/or overlooked diagnoses being investigated, treated and/or worked up. It is simply not enough to identify clinical indicators within the record and use as the basis for generating a clinical query. The clinical facts, information and context as observed, described, told and recorded by the physician must be well orchestrated as part of a complete patient story. The lack of a clear flowing medical record that adequately and sufficiently tells the patient story continually contributes to unnecessary self-inflicted avoidable medical necessity and clinical validation denials. I consistently observe this phenomenon every day as I review medical necessity denials. I can sense a clinical picture yet do not clear see a truly high acuity clinical picture. “Sensing” is certainly not a substitute for explicit consistent clear and contextually correct documentation of the patient’s clinical picture and story.

CDI- Changing Our Approach

Changing our current approach to CDI is no longer optional. Instead it must be considered as a major priority to bring CDI into the forefront of optimal contribution to cost effective valued oriented efficient outcomes-based patient centered care supportive of a high performing revenue cycle. Business as usual whereby the primary focus of CDI is revenue generation is quite honestly not a sustainable business model with any likelihood of longevity. A new year is upon us, what an ideal time to establish a solid plan to reformulate, refocus, rebrand and rethink present day CDI processes for the better. Physicians and their patients are dependent upon us to do the right thing for the right reason, rejecting current approaches to CDI that are predicated upon squeezing as much monies out of the record regardless of the quality of the documentation. In most aspects, CDI in its present format can be characterized as a cat and mouse game with third party payers, the hospital bills a DRG and the payer refutes and challenges the coding and/or medical necessity for the care provided and billed. The provider always seems to be on the losing stick. Time to focus on a more rewarding strategy embracing quality communication of patient care, quality care and compliant optimal reimbursement by nature of optimizing CDI performance with purpose.