Take Stock in Your CDI Program-Check Under the Hood

Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have discounted the necessity to evolve with the times, overlooking critical opportunities to contribute to the overall welfare of the healthcare delivery model. A strong CDI program for the right reasons with an underlying commitment to achieving meaningful measureable sustainable recognizable change in documentation patterns is key to a high performing revenue cycle processes. Complacency is a natural byproduct of an organization remaining comfortable with the status quo, mistakenly believing that the organization is attaining value and results from current processes. Often times the organization’s top executives, the decision makers that approve and fund initiatives receive inaccurate, misguided, counterproductive and counterintuitive advice and direction from consulting companies that purport to be “subject matter experts” in their respective fields. Factor in associations that represent their respective industry who promote and perpetuate the continuation of the status quo in webinars, journals, trade shows, conferences, boot camps and radio shows and you have a recipe for ongoing complacency as the norm. Let’s take a deep dive into the current state of affairs of the Clinical Documentation Improvement industry

Current State of Affairs-CDI

The clinical documentation improvement movement in hospitals initially was rooted in “improving” the quality and completeness of documentation in the medical record. Over time, the industry evolved as a means to meet and address head on a quest to “goose” the case-mix index and resulting reimbursement. While I am a firm advocate and proponent for insuring ideal reimbursement given the high costs of providing quality focused outcomes based patient centric care, the methodology employed in present day CDI processes that are thought to define and accomplish documentation improvement are vested in misnomers and misunderstanding of what the medical record actually stands for.

The medical record serves first and foremost as a communication tool for physicians and all other relevant healthcare stakeholders to best serve the patient’s care needs, whether they be acute episodic conditions managed in the hospital and ambulatory care setting or chronic conditions or preventive medicine provided in the ambulatory settings. When the medical record is treated as and thought of primarily as a reimbursement tool that the CDI profession and the cottage industry of consulting companies serving the profession subscribe to and operationalize, complacency and chasing the all might dollar deeply set in. I encourage everyone directly in clinical documentation initiatives to open the hood and take a real hard look at what is actually being accomplished through finite healthcare dollars spent on CDI initiatives. Conduct a sample review of medical records for purposes of assessing the quality and completeness of documentation and draw your own conclusions as to the state of documentation. Effective compliant and accurate documentation is a fleeing notion with the advent of the electronic health records. CDI is accomplishing very little if anything in the way of long-term sustainable results with the fixation upon querying physicians for additional diagnoses, mistakenly classifying the query process as a form of documentation improvement. Remove the query process as the staple arsenal of CDI and there essentially is no industry or profession; one can easily classify CDI as a one trick pony or one trick magic show.

Engine Trouble-The Repair

The Clinical Documentation Improvement movement is currently experiencing significant engine trouble. The great news is the prognosis can be good and can be certainly dealt with in a cost effective reasonable manner. In the short time I have been in my role as CDI Manager, the program and our current CDI team have embraced and fully supported the concept of affecting real positive change in the quality and completeness of documentation through recognition that physicians are our constituents in the scheme of operations. Physicians are not mere targets for lobbing queries at consistently in the hopes we can achieve our KPI metrics of number of queries and query response rate. Our constituents are physicians who have an overwhelming penchant for learning and doing the right thing for their patients, that is becoming more proficient and skilled in communicating the care provided in a clear, concise, consistent and contextually correct manner. Instead, the CDI team has recognized that current skills sets and core competencies taught at boot camps and reinforced through the plethora of CDI resources being peddled and thought of as the standard for a CDI professional are quite frankly not sufficient. In addition to current skill sets and knowledgebase of CDI, our CDI staff are willing to step out of their comfort zone and acquire the skills and knowledge of what constitutes best practices and principles of documentation that can be readily shared with physicians and residents alike. The model of CDI at our facility is ultimately gearing toward the CDI specialists being held accountable and responsible for moving the needle in regards to achieving accurate complete and logically organized communication of patient care. The true measure of documentation improvement will be an assessment and scoring of the complete record consisting of the H & P, progress notes and discharge summary. Each physician will be provided quarterly with a valid reliable score for their documentation and communication of patient care. Lastly, one of our soon to be Key Performance Indicators will be dollar amount and volume of medical necessity denials since these denials are rooted in insufficient, i.e., poor documentation beginning with the critical H & P. More than 50% of medical necessity denials are directly attributable to insufficient documentation as consistently pointed out in the annual CERT Program report on Paid Claims Error Rates.

Putting the “Improvement” Back in Documentation

It’s time to revisit current CDI processes, determine the current state of CDI and documentation practices at your facility and recognize the contribution your program can potentially make to the patient, the physician and the ancillary healthcare providers in truly improving the breadth and depth of communication of patient care. It is my sincere goal to heighten the CDI profession’s awareness and commitment to the urgent need to modify present day CDI processes, transforming their alignment and integration with established goals of achieving sustainable meaningful measureable improvement in documentation. The status quo and complacency of CDI must change to address the continually changing needs of documentation beyond just reimbursement. Just like in any circus, a splashy act that catches and mesmerizes the audience eventually loses its touch and constantly must be changed to keep the circus the “latest and greatest.” This latest and greatest concept applies to and is relevant to CDI, time to reevaluate and reinvigorate CDI.s