Listen to Glenn cover various points in the CDI arena. You can check out the website this podcast is featured on here.

The use of case-mix as a proxy for judging the effectiveness of clinical documentation improvement programs can be characterized as an unreliable imprecise measure of overall success. While case-mix over time can potentially increase over time as clinical specificity in diagnoses capture improves, there are a myriad of contributing factors that control the ultimate calculation of case-mix. Attributing improvement in documentation to increases and fluctuations

As many of you are aware, I have been advocating passionately for a total transformation of current CDI processes that have virtually remained stagnant for the past twelve plus years. This transformation in CDI requires a two-pronged approach to be successful in execution, the first consisting of rebranding and reformulation of current CDI processes that have demonstrated over time to be ineffective in achieving any meaningful, measurable, sustainable improvement

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

CDI programs have strong potential to significantly raise compliance risks for the hospital or health system in which the program operates. Compliance departments strive to minimize and alleviate the numerous risks associated with the myriad of components associated with and fundamental to the delivery of healthcare. Clinical documentation improvement initiatives can work in tandem, align and collaborate with the compliance department’s goals and objectives,

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

Today’s model of CDI predicated upon retrospective reactive repetitive queries fails to achieve scale and sustainable improvement for a variety of reasons. The biggest obstacle to achieving true documentation improvement over time as individual hospital programs mature is the current system is not designed or intended to positively affect any patterns of documentation beyond diagnoses typically appearing in the chart 24 to 48 hours after admission to the hospital.

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

The Ideal State of CDI- Collaborating Synergistically With All Other Ancillary Healthcare Roles to Achieve Real Meaningful Improvement in the Communication of Patient Care. Let’s Not Forget the Patient in any CDI Initiative. Reimbursement is a byproduct measure of documentation improvement that is sustainable over time. Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 billion annually. Interesting enough the following statements in the article run contrary to findings of a study published in January’s Health Affairs