Common challenges in clinical documentation improvement (CDI) processes, particularly regarding physician documentation, are overreliance on artificial intelligence tools and other CDI software that tend to minimize the physician’s duties and responsibilities in producing a complete and accurate note. These tools must be considered as workarounds, allowing the physician to relegate his/her documentation to autopilot and detracting from the adequate capture and reporting of the physician's clinical judgment, medical decision-making, and clinical reasoning.  Simply feeding physicians with queries and using AI or generative scribes to assist with documentation will not inherently improve the quality of their documentation or encourage long-term learning that is sustainable over time.

Here are a few key thoughts that could help address this issue:

1. AI Tools Need to be a Supplement, Not a Replacement

AI tools like generative scribes can assist physicians in documentation, but they cannot replace the core need for physicians to understand and improve their own documentation practices. These tools should support the physician in understanding how to capture the right clinical nuances rather than doing the work for them. Essentially, AI should act as an enabler, not the main actor. The CDI profession can serve as guides, educators, and facilitators to better physician documentation provided they recognize the inherent limitations of issuing physician queries as the fundamental basis for clinical documentation integrity.

2. Educating Physicians is Key

If physicians are continuously spoon-fed queries, they won't develop the necessary skills to navigate documentation independently. Instead, there needs to be an emphasis on ongoing education and training around accurate, thorough documentation practices. Physicians need to be empowered to understand the "why" behind each query and the importance of capturing detailed information for the patient’s care, establishing medical necessity, telling and describing the patient’s clinical story, and progress of the patient, and supporting accurate optimal coding generating optimal sustainable durable revenue.

3. Shift to Collaborative Documentation

Instead of relying heavily on external prompts (like queries or AI-generated suggestions), the ideal is a collaborative approach to documentation. This can involve working closely with physicians to understand their thought processes, offering feedback, and creating an environment where physicians are motivated to actively engage in the documentation process. This approach could also involve clinical documentation specialists (CDS) and coders acting as partners, rather than as auditors or enforcers.

4. Real-Time Feedback

Another important aspect is real-time feedback that focuses on teaching, rather than just correcting mistakes. For example, after the documentation process, physicians could be given suggestions on how to improve or clarify their documentation, followed by a discussion that enhances their understanding. This can take the form of one-on-one physician documentation feedback and tip sharing or the conduct of short educational sessions where individual cases can be discussed. Retrospective, reactive, repetitive queries do not constitute “real-time feedback” that positively changes physician behavioral patterns of documentation.

5. Moving Beyond “Query Fatigue”

Many physicians experience "query fatigue"—becoming disengaged or overwhelmed by the constant stream of documentation queries. Instead of bombarding them with questions, a better strategy is to provide high-value, low-volume queries that are linked to education. This could make the documentation process feel more like a teaching opportunity rather than a burdensome task. Automated queries produced by CDI software create a query fatigue environment where physicians distance themselves and become more disengaged in CDI programs. Consider the following from a prominent CDI software company: “Concurrent uses AI to prioritize cases with the highest revenue potential, so your team’s expertise is used where it matters most. Proven Results:- 100% lift in query volume from baseline in the first year.” Notice no mention of physician documentation training and the impact of 100% lift query volume.

6. Documentation Culture Change

Ultimately, what’s needed is a cultural shift in how physician documentation is viewed within the healthcare system. It should be seen as an integral part of patient care, quality measurement, and reimbursement, not just an administrative task. When physicians understand the significance of documentation at a deeper level, they’re more likely to invest in improving their documentation practices on their own.

In summary, it seems the challenge lies not just in the tools available but in how they're integrated into a broader strategy of physician education, empowerment, and engagement. Rather than relying on tools alone, the CDI profession needs to encourage physicians to actively take ownership of their documentation practices, promoting a long-term shift toward excellence. Rather than the profession referring to itself as “Clinical Documentation Integrity,” it should embrace the notion of “Physician Documentation Excellence” and “Communication Documentation Excellence.”  The profession must incorporate elements of physician documentation training, providing physicians with knowledge, resources, and tools to master documentation and achieve physician documentation excellence.

Core-CDI offers physician-to-physician documentation training provided by practicing hospitalists, engaging physicians in learning about and becoming better documentarians, achieving communication documentation excellence sustainable over time with durable net patient revenue. Reach out to learn more about how Core-CDI can transition current CDI programs from reactionary to proactive with physician achievement of proactive preemptive denial avoidance documentation.