A recent conversation with a vice president of the revenue cycle for a large multi-hospital health system evolved into an active conversation on the merits of a fully staffed clinical documentation improvement (CDI) program versus a fully staffed and fully operational high-performing program. The two are distinctly different in their ability to achieve the traditional key performance indicators associated with most CDI programs.
What ensued was an observation that I am consistently experiencing throughout the country in most CDI programs, potentially detracting from our profession’s ability to accomplish and maintain optimal improvement in the quality and completeness of medical record documentation.
The Role of Benchmarks in Driving and Measuring Operational Performance
Every business initiative has an associated benchmark to evaluate and measure ongoing performance and successes, calculating an ultimate return on investment reported to the administrative level. CDI programs are no exception with benchmark performance measures including the customary key performance indicators consisting of the following:
- Number of charts reviewed and queries generated
- Physician query response rate and agreement rate
- MCC/CC capture rate
- Number of chart follow-ups
- Coder and CDI MS-DRG agreement rate
- Surgical and medical case mix index (CMI) increase
- Additional revenue generated.
These measures help to drive continual performance improvement through ongoing CDI specialists’ training and education as well as “fine-tuning” of the program. However, a valid question needs to be asked of whether benchmarking of a program utilizing said key performance indicators (KPIs) is truly indicative of and a telltale sign of a fully staffed and fully operational CDI initiative.
A fully staffed program with present-day processes of CDI using queries as the hallmark foundation for quantifying documentation improvement does not necessarily assure operational excellence and high-performance achievement. A high-performing CDI program truly achieves noticeable improvement in the quality and completeness of documentation, and closely aligns, integrates and positively contributes to the revenue cycle while best communicating the patient care for all relevant healthcare stakeholders.
Quality and completeness of documentation relate to accurately reporting and reflecting the following:
- Where has the patient been?
- Where is the patient now?
- What am I thinking?
- Why am I thinking it?
- Where am I going?
- What am I going to do when I get there?
- What are my contingency plans?
- What timeframe am I thinking about, and what are my discharge plans?
The operational status quo of CDI programs as they exist today may have been sufficient by historical standards, yet by today’s standards they require a close reexamination with a keen eye towards revamping, revitalizing, reorganizing, reengineering and rebranding. Let’s look at outlining and defining broadly the critical key elements of a fully operational CDI program—one that measurably conquers inroads and overcomes obstacles to improve the quality and effectiveness of physician clinical documentation to the extent that all ancillary functions and roles directly dependent upon accurate and complete documentation can effectively be executed. Ultimately, the patient is the primary benefactor when documentation provides for fully informed coordinated care.
A Fully Operational High-Performing CDI Program
The critical elements of this type of CDI program include a common theme that incorporates a vision and purpose of documentation extending well beyond diagnosis capture. The purpose of complete and accurate patient-record documentation is to foster quality and continuity of care. It creates a means of communication among providers and among providers and patients, family members, and/or others about health status, preventive health services, treatment, planning, and delivery of care.
The North Carolina Medical Board offers a very thorough Position Statement on Medical Record Documentation Position Paper. It says that the medical record is a chronological document that:
- Records pertinent facts about an individual’s health and wellness
- Enables the treating care provider to plan and evaluate treatments or interventions
- Enhances communication between professionals, assuring the patient optimum continuity of care
- Assists both patient and physician to communicate to third-party participants
- Allows the physician to develop an ongoing quality assurance program
- Provides a legal document to verify the delivery of care
- Represents a source of clinical data for research and education.
Fundamental to an effective CDI program is equipping CDI specialists with the skill sets, core competencies and knowledge base required to be able to identify, recognize and address insufficiencies in physician documentation correlating with our profession’s title of “clinical documentation improvement specialists.” We must possess the expertise and confidence in sharing actionable knowledge with physicians on standards of documentation that may have been overlooked or insufficiently documented.
Standards of documentation can vary widely, yet there are core components of documentation that serve as a foundation for good quality-focused, quality-oriented, patient-centered, cost- effective care delivery. They are as follows.
- The record reflects the purpose of each patient encounter and appropriate information about the patient’s history and examination, and the care and treatment provided are described.
- The patient’s past medical history is easily identified and includes serious accidents, operations, significant illnesses and other appropriate information.
- Appropriate age-related family history is recorded.
- Medication and other significant allergies, or a statement of their absence, are prominently noted in the record.
- When appropriate, informed consent obtained from the patient is clearly documented
- All drug therapies are listed, including dosage.
- All consultation, laboratory and imaging reports should be entered into the patient’s record and reviewed by the practitioner who ordered them. That review should be documented. Clinically significant abnormal reports should be noted in the record, along with corresponding follow-up plans and actions taken.
- Information regarding personal habits such as sexual behavior, smoking, and history of alcohol use and substance abuse or dependence, or lack thereof, should be recorded.
- An updated problem list is maintained. This is truly a physician’s responsibility.
- Patient’s chief complaint or purpose for the presentation to the hospital for care is clearly documented and recorded in the patient’s own words.
- An accurate and complete history of present illness (HPI) is taken and documented by the physician, emphasizing “present illness” versus “past illness.” The extent of the recorded HPI should be clinically relevant and sufficient to capture as many appropriate elements as necessary to depict, describe and show the patient’s severity of signs, symptoms and problems.
- A physical exam is conducted congruent with the nature of the patient’s nature of presenting problem and the physician’s clinical judgment. The depth and degree of the physical exam performed is reasonable and necessary based upon the patient’s presenting signs and symptoms, past family social history, comorbid conditions and current risk factors.
- Clinical assessment is expressed with definitive diagnoses as well as appropriate provisional diagnoses when warranted with inclusion of clinical rationale, clinical criteria, thought processes and medical decision-making. Other relevant chronic conditions impacting management and/or workup of acute clinical conditions should be included in the assessment, insuring to use appropriate clinical specificity for both acute and chronic conditions with the enhanced reporting capabilities afforded under ICD-10.
- Each acute condition, either definitive or provisional, must be able to be traced back to the patient’s presenting signs and symptoms and supported by abnormal physical exam findings as well as radiological and other available diagnostic workup results.
- The plan of action and treatment is congruent with the assessment and can be linked to each clinical condition under active management that occasioned the hospitalization and/or impacts the management of these conditions.
- Requests for consultations are consistent with clinical assessment and physical findings. The clinical assessment must support the decision for a referral, and the recommendations of the consulting physician must be acknowledged and addressed in documentation to insure a clear picture of the attending assuming and driving the daily care, piloting the ship.
- Daily progress notes include sufficient information to adequately reflect the patient’s ongoing complaints, interval history-recording of patient’s ongoing clinical situation, physical exam, results of any diagnostic tests (radiology reports, lab results, etc.), any new signs and symptoms or disease processes, plans for further or continued work-up, and general progression of the patient’s clinical conditions to include a clear picture of patient’s response to treatment or lack thereof. In short, the patient’s progress and clinical stability should be clearly documented in the progress note, limiting the use of the cut-and-paste function and carry forwards without updating the content as needed to best express the clinical picture and progression of the patient, expected versus actual.
- Discharge summary should be completed in a timely fashion and at a minimum include the following six components as part of the standards of discharge summaries as stipulated by the Joint Commission.
- Reason for hospitalization
- Significant findings
- Procedures and treatment provided
- Patient discharge condition
- Patient and family instruction (as appropriate)
- Attending physician’s signature,
Achieving Excellence with Fully Operational CDI
Capitalizing upon a fully staffed CDI program, we must invest the energy, dedication, devotion and commitment to transforming current CDI processes, structural framework and daily operations from a significantly narrowed focus to one that incorporates breadth and depth resonating with achievement of quality-focused documentation. This requires an expanded viewpoint, respect and acknowledgment of the purpose of clinical documentation, recognizing the potential value we bring to the table in enhancing the communication of patient care.
Transforming and evolving CDI as a profession collectively and individually is admittedly going to take a village and simply is not going to occur overnight. A reasonable starting point is to make a compelling argument and case for bucking the current trend of CDI in light of the expanded use of clinical information necessary under value-based healthcare delivery models. Effective and complete documentation assumes new meaning given all the ancillary uses of clinical data dependent directly upon accurate communication of patient care. Let’s not let the status quo of CDI and apathy detract from advancing our professional careers.