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. What’s wrong with this approach to CDI? First, by definition it is retrospective in nature. Often, the query is soliciting the inclusion of a diagnosis in the assessment that is no longer supported by the clinical indicators, clinical information and facts of the case on the day the query is issued. Case in point that is quite frequent, the CDI specialists’ queries for acute respiratory failure on day two in a pink puffer blue bloater COPD exacerbation patient admitted through the Emergency Room in clear failure. Meanwhile, the information in the chart fails to support the diagnosis on day of query, adding ammunition for the outside third party-payer reviewer to refute and disallow the diagnosis. Simply stated, a diagnosis appearing days after the diagnosis is relevant is certainly not conducive to effective communication of patient care, severity of illness and acuity reporting, and inarguably not spatial in time.

Where Should the CDI Process Begin?

I often ask CDI leadership why their CDI team is bent and fixated on waiting until the patient is in the house for one to two days to review the chart when sufficient clinical information is frequently available on the day of admission that permits clarification of definitive and/or provision diagnoses. The answer I generally receive is “there is not enough information in the record to query the physician. This response does not hold water if the overall goals and objectives of the CDI program are to improve documentation. Improved enhanced documentation requires a commitment, dedication, recognition and treatment of the medical record as a communication tool first and foremost as opposed to a reimbursement tool. Here is where CDI’s current efforts and focus fail to align with processes that foster and achieve actual documentation improvement. What should the process entail that supports and brings to light meaningful documentation improvement that best serves the needs of all relevant healthcare stakeholders including most importantly the patient?

Here is the ideal model I envision for CDI leadership, CDI specialists and the C suite to embrace moving forward to advance the contribution and impact of our efforts at documentation improvement. Begin the CDI process preferably in the Emergency Department with well organized well thought out initiatives to capture the severity of illness of the patient through accurate reporting and reflection of patient’s Chief Complaint, History of Present Illness, all vital to depicting the patient’s nature of present problem. These elements are crucial in setting the tone, in conjunction with the Past Family Social History, Review of Systems, Physical Exam and results of diagnostic workup and patient response to treatment performed in the Emergency Department, provide a well laid out organized clinical picture of the patient at time of decision to admit to the hospital. The assessment or clinical impression should be supported by the clinical facts, clinical information and clinical context outlined in the ED documentation, accompanied by inclusion of the physician’s clinical judgment, medical decision making, thought processes and clinical criteria utilized in formulating a definitive or provisional diagnosis. Lastly, every physician order in the plan of care should correlate with an acute or chronic diagnosis, diagnosis or sign and symptom for optimal tying together of all the clinical information appearing in the record thus far. The assessment should clearly represent where the physician is with the patient, what the physician is thinking and why and the plan should represent where the physician is going and what is he going to do when he gets there.

Why Is this the Most Conducive Model for CDI to Consider?

This type of CDI model begins and supports the patient story from the very start of presentation to the Emergency Department, allowing the hospitalist or other attending physician to incorporate a clearly defined account of patient care into his/her thought processes, performance and documentation of his/her History and Physical exam, forming the basis for establishment of medical necessity for physician work performed as well as need for admission to the hospital. To this end, we have solid and complete documentation right from the start with a logical flow of information that accompanies the progression of the patient from the ED to the hospital floor and beyond. This means of capturing and reflecting complete and accurate clinical documentation best serves and supports the case management/utilization review staff’s roles of advising physician on the most clinically appropriate level of care while providing the necessary information for communication with third party payers, not to mention communication with other healthcare stakeholders integrally involved in the patient’s care. Clinical information and facts of the case are better situated and lend themselves to the diagnosis querying CDI performs, allowing the record to speak for itself while alleviating the voluminous number of unnecessary avoidable self-inflicted medical necessity, clinical validation denials and DRG down-codes.

This is the ideal model of CDI, strengthening and furthering the CDI specialist’s dedication and commitment to achieving true sustainable documentation improvement we can be proud of.