Documentation becomes meaningful when using evidence-based medicine.

I see a lot of conversations ongoing about clinical documentation integrity (CDI) efforts that in my opinion, seem to reflect a less-than-productive way of gaining progress. CDI should be about documenting for evidence-based medicine, and not coding guidelines.

Coding guidelines have no place in the physician’s documentation of the patient’s journey. Documentation should only be in place for capturing the clinical evidence of the patient encounter. But often that gets sidetracked by vendors and others setting up electronic health records (EHRs) or physician documentation templates.

Dropdowns or pick-boxes that solely focus on hitting required elements or bullets fail in capturing what is truly needed for physicians to document what is needed to illustrate the patient’s true clinical condition. Utilizing these types of corner-cutting methods, or focusing on creative ways to document for coding rules, fails a physician and the patient every time. What it does is put us in a position of defense: being forced to defend our reasons for ordering tests/services, our documentation under quality reviews, our reasons for choosing diagnosis codes, etc.

The most effective way of setting up templates or assisting physicians with faster ways of documenting is to utilize evidence-based medicine (EBM) templates. It is a platform used to make clinical decisions on the treatment of the patient. It integrates clinical experience and patient values with research information. It is constantly evolving, with new data, technology, and outcomes.

EBM is also used to develop clinical indicators, coverage decisions, and payor policies. Clinical indicators use evidence-based medicine. For those working in surgical practices, you are most likely very familiar with these guidelines, as many times when we need to get services or items approved, it is the data that we give to the health plan to get it done. Outside of that, though, they give us well-defined information regarding clinical conditions.

When we focus our efforts on EBM, we are actually enabling our providers to document for each individual patient journey. When we document in this fashion, we then actually hit coding elements, quality elements, etc. Documentation then becomes meaningful.

Instead of showing physician sequencing guidelines or evaluation and management (E&M) bullet points, reference an evidence-based medicine guideline. This is more meaningful for a provider and makes sense from a true clinical experience. As we move more toward episodic payments and advanced payment models, the need for true evidence-based medicine documentation will become even more apparent.

Making the transition for documentation purposes is relatively simple. You can get them from your specialty societies, sometimes on the National Institutes of Health (NIH) website, or from a vendor offering a paid version that includes a physician guide with coding; you can purchase these at Guideline Central. Incorporating these types of documentation concepts into your operations will take the frustration of administrative burden out of your practice and allow you to focus on other, more pressing issues.

Programming Note:

Listen to Rhonda Buckholtz report this story live during Talk Ten Tuesday today, 10-10:30 a.m. EST.

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