The Future Can Be Bright…

A recent conversation with a CDI colleague of mine raised several interesting points I would like to share for consideration. We were discussing an initiative where the CDI specialists and their department were going to transition to working on the floor reviewing records with the intent of conversing more with the physicians and residents on documentation improvement opportunities. The impetus of the initiative to transition to the floor was to be more readily available to the physicians for purposes of discussing cases with pertinent opportunities for documentation enhancement. Ultimately, the goal of his CDI program is to expand efforts at improving the depth and breadth of the documentation to the extent the record best communicates and portrays the quality of care and outcomes achieved. An additional goal of the CDI program is to reduce the number of queries for diagnoses, getting the documentation right the first time without the need for repetitive transactional queries for the same diagnoses every day. This affords more time and energy to collaborate with physicians in a more proactive participatory manner to improve the quality, completeness and accuracy in documentation of the patient’s story.

The Ideal Goal of CDI

CDI’s main goal should be to improve the physician’s ability to consistently describe, show and tell the patient’s story in as much detail for everyone who reads the documentation to completely understand the story, what was wrong with the patient, where was the patient, where is the patient now, what is the diagnosis or diagnoses with appropriate clinical specificity, what is the physician thinking and why and where is the physician going. To this end, the entire patient story is displayed with a clear introduction, body and ending in the form of sound and complete ED documentation, H & P, progress notes, consultant notes and discharge summaries. I sensed the CDI specialist was concerned for the potential to disrupt the status quo of chart review and subsequent query generation as the CDI was now expected to provide and share documentation tips and seek diagnoses clarifications through engagement of physicians in a dialogue. My colleague’s viewpoint was he would not be able to review as many charts as expected, identify as many query opportunities as possible to achieve the designated expectations and goals, achieve a predetermined CC/MCC capture rate, and bring in as many dollars as possible. The underlying logic in this thought process is that it simply is counterproductive and counterintuitive to achieving sustainable documentation improvement over time. Number of records touched and reviewed for initial review and follow-up certainly has no bearing upon measurement and achievement of worth-while documentation improvement. A quick review of most inpatient records at any hospital today will demonstrate that the CDI profession’s overall success in improving the quality and effectiveness of general documentation is dismal at best. An unrelenting focus upon diagnoses capture overlooks a critical part of the medical record, that is the patient story as evidenced by a clear succinct consistent and contextually correct clinical information, facts of the case, and clinical context. The present electronic health record consists of a hodgepodge of information copied and pasted with blown in information such as lab values, radiology reports and other diagnostic work-up results. History of Present Illness recordings are more of an account of past illness devoid of describing, showing and telling the patient’s true severity of illness and signs/symptoms. The active problem list is not up-to-date with inaccurate diagnoses being captured and recorded, the assessment is often incongruent with the patient’s presenting signs and symptoms, there are other diagnoses being considered as part of the patient workup that are not recorded and a rational plan of care compared to the assessment is not recorded. In short what we have is a medical record that creates a picture of challenging situational awareness where it is virtually impossible to identify the patient within the story.

CDI-A Better Way

A “Better Way” of clinical documentation improvement is for my colleague and the profession to embrace change in fundamental CDI processes that have proven their inability to bring positive change in physician behavioral patterns of documentation. A better way begins by recognizing and treating the medical record as a primary communication tool for patient care. Germane to CDI is an encompassing review of the record with identification of documentation insufficiencies including accurate and complete diagnoses capture. Building upon this core review process, CDI must embrace the concept of record review in the context of securement and achievement of documentation that communicates, describes, shows and tells the patient story in a consistent organized fashion. Affecting notable sustainable positive change in documentation requires CDI commitment to understanding ourselves what constitutes complete and accurate documentation and even more importantly how to engage physicians in a discussion on how best to achieve documentation excellence while saving precious time. Diagnosis reporting while inarguably important is not the end all and be all of documentation improvement. A medical record where the physician understands and sufficiently communicates, describes, shows, and illustrates the patient story supported with recording of all relevant clinical diagnoses and associated clinical judgment and medical decision making constitutes real documentation improvement. I submit to CDI specialists including my colleague to avoid becoming overwhelmed and narrowly focused upon diagnoses recording only. An organized well thought out CDI process that drives real improvement in documentation completeness and effectiveness, accurately reporting and reflecting the patient story and progression of patient care, will undoubtedly arrive at the same endpoint of appropriate optimal reimbursement. The reimbursement will be of more legitimate nature maintainable over time. I encourage my colleague and the CDI profession as an entity to fully embrace, support and advocate for change in the current structural processes of CDI as they currently exist. Recently attending the National Physician Advisor Conference in Greenville, SC, I am even more convinced CDI can play a tremendous role in making it mark in improving and enhancing the quality of communication of patient care. We have just barley scratched the surface in achieving documentation improvement with current processes. The time is ripe for advancement of a transformative movement for the clinical documentation improvement industry. Our future depends upon the ability and commitment to change; overreliance on present day transactional processes of CDI lends itself to obsolescence ad ultimate downward trajectory