Creating a Successful Effective Physician Documentation Improvement Program- Changing Course

Clinical documentation improvement has evolved over the last ten years with the advent of the electronic health record and the ability to use natural language processing and other key software to enhance the overall efficiencies and effectiveness of medical record chart reviews. This facilitates the identification of opportunities for diagnoses reporting, hospital acquired conditions and patient safety indicator clarifications. As a whole the profession has not kept up with and adapted to the new age and transformation of the healthcare delivery model with increasing needs for solid, complete, effective and concise clinical documentation that accurately reports and reflects the true care provided. The profession has overlooked the realization that current CDI processes fail to align and integrate with the ongoing changes in the uses of healthcare reported data predicated upon complete and accurate clinical documentation. Let’s take a close look at where CDI is today and what are the key steps to consider in reengineering, reformatting and revamping your present CDI structural processes and outcomes.

Today’s CDI Initiatives

Today’s CDI initiatives for all intensive purposes is focused primarily upon improving diagnoses reporting with the ultimate goal of optimizing reimbursement through DRG Assignment. An additional focus centers upon accurate capture and reflection of data integral to quality reporting measures such as severity of illness/risk of mortality, observed versus expected mortality, risk of readmission, hospital acquired conditions and Patient Safety Indicators. While I would not downplay the importance of these elements and concepts that drive reimbursement in some form and fashion, this unrelenting focus upon diagnoses reporting masks a crucial element devoid in most CDI programs consisting of achievement of valid reliable measurable sustainable documentation improvement. It goes without saying that all CDI programs must be self-sustaining and positive revenue producing in today’s business economic climate cost conscious value-based healthcare delivery models. Value based healthcare can be defined as outcomes as a factor of costs, outcomes divided by costs of care. Looking at a more simplified model of value- based healthcare care consists of providing the right care at the right time for the right reason in the right setting with the right clinical judgment and medical decision making with the right plan of care with the right documentation. Each and everyone of these components that address value-based healthcare delivery are grounded upon the quality of clinical documentation supported explicitly through accurate depiction and reporting of the clinical facts, clinical information and context of the patient encounter. The lack of focus and direction of present day CDI programs upon achieving realizable improvement in the quality of the clinical documentation aside from diagnoses reporting detracts from the practice of medicine in real terms. Quality of care strongly correlates with the quality of medicine provided, the two are inseparable and integrally related

Where Should CDI’s Focus Be-Going in the Right Direction

CDI as a profession must recognize the urgent need for change in present day CDI practices. The notion that CDI is principally associated with CC/MCC capture rate, DRG optimization, strategies for DRG shifts and reimbursement enhancement is simply put contrary to the real meaning of documentation improvement. I am firmly convinced that until CDI as an entity recognizes the pressing need to transform its viewpoint of the medical record as a reimbursement tool to one more widely embracing the recognition of the medical record as a communication tool for fully informed coordinated care, we will continue to be travelling in the wrong direction. CDI going down the right path in the right direction requires an ongoing commitment to acquire the core skills and deep knowledge that provides the opportunity to affect positive change in the quality and completeness of documentation. Once equipped with the requisite skills, knowledge and core competencies, only then will CDI be able to find its way to demonstrate and achieve meaningful sustainable improvement in documentation. What I am referring to as skill sets, core competencies and knowledge is the confident ability of the clinical documentation improvement specialists to review a record, identify noteworthy deficiencies in documentation that need to be addressed with the physician and the wherewithal to collaborate with physicians as colleagues in consistently improving the breadth and depth of documentation of patient care. Breadth and depth certainly does not imply more physician documentation; instead it implies more effective, clear, concise, consistent and contextually correct documentation of patient care. Judicious use of cut and paste and carry forward documentation practices, something widely abused and misused today, is definitely in order and must be addressed swiftly. CDI plays an integral role, not sole role, in addressing the epidemic perils of cut and paste and patient safety.

How Best to Acquire the Skill Sets and Core Knowledge- Moving in the Right Direction

CDI acquiring the skill sets and core knowledge enabling and facilitating the profession moving in the right direction and truly improving the quality, completeness and effectiveness of documentation demand a CDI commitment to self-learning beyond current core knowledge and practices. CDI boot-camps and rote canned approaches to chart reviews searching for diagnoses must be replaced by a philosophy that incorporates a holistic approach embracing the entire clinical picture versus narrowly focused diagnoses reporting.

Recently, I turned a new page in my career, as a CDI Manager and have begun the process of reengineering and redirecting the focus of the CDI program. Our CDI team is both enthusiastic and eager to learn about and become fluent in practices of documentation that represent the best practice standards and principles. Stay tuned for an upcoming white paper outlining key steps and concepts to consider in transforming a CDI program from reactive to proactive in affecting positive change in physician behavioral patterns of documentation. In the interim, I encourage you to take a hard look at the current makeup of your CDI program and begin taking conscious steps to transition away from strict focus upon reimbursement; strict focus upon case-mix increase and reimbursement as an outcome of CDI is counterproductive, counterintuitive and misaligned with goals of meaningful sustainable documentation improvement.