CDI-Tremendous Unrealized Potential

Clinical documentation improvement programs can potentially serve a wide array of beneficiary purposes besides improving revenue capture and optimization if offered the opportunity. Present initiatives at documentation specificity, while inarguably important and valid under ICD-10 processes, are primary limited to basically scratching the surface when compared to the tremendous unrealized potential  we as a profession can accomplish in affecting real time positive change in physician overall behavioral documentation patterns . The standard of effective and complete documentation should create a byproduct of optimal reimbursement for the right care at the right time for the right reason in the right forum with the right documentation versus present day efforts at “documentation improvement” for reimbursement as the strict endpoint.

Scratching the Surface

Today’s initiatives at clinical documentation improvement within the electronic health record are merely scratching the surface when examining the Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper from the American College of Physicians (  The following policy recommendations for clinical documentation in the article caught my attention for many reasons if not from a true clinical documentation improvement standpoint:

  • The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
  • The clinical record should include the patient’s story in as much detail as is required to retell the story.
  • As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.
  • Clinical documentation in EHR systems must support clinicians’ cognitive processes during the documentation process.

Taking a Closer Look at CDI

Today’s focus upon clinical documentation improvement fails to add meaningful value to the communication of actual patient care rendered and certainly does little to enhance communication accuracy and completeness of the patient story. Take a fairly typical case of a patient who is admitted with chest pain from the Emergency Room with excruciating chest pain of three days duration with no past or family history of chest pain or myocardial infarction. Patient is admitted to the hospital as an inpatient with a reasonable expectation by the admitting hospitalist of at least a 2 midnight under Medicare’s two mid-night rule based upon the duration of the patient’s chest pain and lack of clinical response to workup and management in the Emergency Room. The clinical documentation improvement specialists will review the chart within 24 hours of admission to determine of a compliant clinical query is appropriate for sake of clinical specificity and ultimate coding and DRG assignment as well as resulting reimbursement. I am not advocating against or downgrading the role of CDI in this picture; instead, I am pointing out the fact the clinical documentation improvement specialists is simply not taking advantage of the opportunity to enhance the communication of patient care by solely honing in on the documentation of clinical diagnoses with appropriate clinical specificity.

In today’s current healthcare operating environment where hospital spending from $526.2 billion in 2003 to $936.9 billion in 2013 (Kaiser Family Foundation), it is not surprising for increased scrutiny and focus upon the medical necessity, need for and outcomes of hospital level of care. Witness the Medicare and other third party payer alternate payment alternate payment arrangements and initiatives that are intended to drive improved outcomes, enhanced efficiencies in care delivery and produce value in all aspects of patient care regardless of setting. We are quite familiar with some of these Medicare initiatives to promote and reimburse for quality versus quantity of care, i.e., Readmission Reduction Program, Hospital Acquired Conditions, Value Based Modifier program, Medicare Spending per Beneficiary, and Bundled Payment for Care Improvement Initiatives.

 If I was to identify the major limitation in current CDI initiatives, I would summarize with the word “context.” Context may be defined as the situation where something happens; the group of conditions that exists where and when something happens. A major constitution of effective and complete clinical documentation is an explicit account of the clinical facts of the case, what is happening with the patient; why did the patient present to the Emergency Room; what transpired into the ER; what was the ER physician and attending physician thinking when a decision is made for inpatient admission or observation status; what provisional diagnosis(es) or definitive diagnoses was the physician entertaining when admitting the patient; what therapeutic treatments or diagnostic workup was planned upon admission to help establish medical necessity for hospitalization; does the documentation available at time of admission and throughout the stay support the intensity of evaluation and/or treatment, including thought processes and the complexity of medical decision making. Medical decision making may be defined as the thought processes of the physician, the complexity of establishing a diagnosis and developing and selecting a management and treatment option for the patient. I could go on and on about documentation improvement opportunities we are not attune to and focused upon in present day-to-day CDI duties and responsibilities. The mere capture of CC/MCCS and principal diagnosis specificity as conclusory statements without documentation of the clinical context emphatically serves no real purpose from a communication of patient care perspective. As mentioned in the ACP’s position statement above, clinical documentation within the EHR should facilitate seamless patient care to improve clinical outcomes as well support clinician’s cognitive processes during the documentation process. Inarguably, documentation of conclusory diagnosis statements as a result of the query process does little to address seamless patient care or recording of physician cognitive skill sets, clinical judgment and medical decision making associated with and an integral component of the practice of medicine.

 Beginning Points

Two areas of clinical documentation focus that will have a major impact on context of admission and continued hospitalization in support of the diagnostic conclusory statements we elicit through the query process include improving the clinical documentation and recording of the physician’s clinical judgment in the H & P as well as adequacy and completeness of the progress notes. Adequacy and completeness of progress notes may be judged by the use of the following descriptive snapshot of the patient each and every day the physician evaluates the patient and records the encounter:

  • Is the patient unstable or has developed a significant complication or a significant new problem
  • Is the patient responding inadequately to therapy or has developed a minor complication
  • Is the patient stable, recovering or improving


Cut and paste and carry forwards if used as part of the documentation must be used with caution and attention to updating the present information to reflect the patient’s care and condition each and every day. An effective progress notes meets the following characteristics:


  • Factually correct
  • Temporally relevant (no future tense references to procedures already done)
  • Concise (no fluff; just a concise statement of the facts)
  • Devoid of plagiarism
  • Analytic – (reflects thoughtful analysis of patient’s diagnosis, status, and

treatment options)

  • Reflective of collaboration (acknowledges collaboration with house staff, nursing,

and other consultants)


The dangers and pitfalls of cut and paste and carry forward practices of documentation are not going unrecognized by third party payers including Medicare, the OIG and the Joint Commission both from a fraud and abuse standpoint as  well as safety issue. Take a moment to read an article titled Preventing Copy-and-Paste Errors in EHRs published February 25, 2015.  (


Lastly, our efforts at affecting positive change in clinical documentation must be definition embrace the physician recording of his/her clinical judgment in support of the conclusory statements we seek from our compliant clinical queries. Clinical judgment is defined as the physician’s assessment of the patient’s clinical scenario and the initiation of action congruent with the documented assessment. The crux of our documentation improvement efforts should be evaluated and judged by the accurate and complete recording of this clinical assessment and congruency with the conclusory statements of diagnoses we seek and clarify that best substantiate the care provided and outcomes achieved. Let us not lose sight of the accurate recording of the patient story including circumstances of admission, all relevant conditions being managed and addressed while hospitalized and most importantly the clinical context that properly and appropriately frame the patient story.


Stay tuned for my next piece discussing the potential role clinical documentation improvement specialists play in working with other stakeholders in defining and promoting a valid and reliable standard of clinical documentation effectiveness within your facility.