Now that ACDIS Annual National Conference has concluded, this is an excellent time to revisit and potentially revise and revamp our current clinical documentation improvement initiatives. Clinical documentation improvement, while considered a service business, is quite similar to most other product lines in the sense of finite and distinct end point life cycles. Take automobile manufacturing as an example; a new car is introduced with much fanfare, advertising and marketing to stir up interest and traffic to automobile dealerships. Specific car offerings stay constant for extended model years with minor revisions, updates and features while basically keeping the same car underpinnings. The grille might change, the tail lights may be updated, a new engine may be offered as an option and more standard electronic features may be offered as standard or optional equipment.  In essence, the car remains basically the same for several model years until competition offers a “better product” and the automobile manufacturers arrive at the conclusion based upon sales volume and amount of sales incentives required to move car production that a totally revamping of a particular car is in order.

The clinical documentation improvement field, analogous to car manufacturing, has nearly reached its “shelf life,” clearly requiring a hard look at revisiting, revising and revamping its purpose, objectives and overall focus and intent. There are a variety of reasons for my assertion that a total overhaul of the CDI process is in the best interest of the profession. In my travels throughout the country, a consistent message themes from stakeholders of the medical record including physicians, case managers, utilization review/management staff, coding staff as well as denials and appeals departments unequivocally are that clinical documentation improvement specialists are not making measurable inroads in actually improving the quality and effectiveness of clinical documentation beyond securing diagnoses that artificially raise the hospital’s case mix index and resulting reimbursement to the hospital.

As I highlighted in a previous post, Palmetto GBA, a MAC contractor for CMS in the southeast, outlined in their review of the top 25 MS-DRGs (Spotlight on Physician Querying and Coding Specific Diagnosis Related Groups) in their jurisdiction findings of at least a 90% denial rate for short stays based upon medical necessity. I am confident in saying that clinical documentation improvement specialists actually reviewed some of these hospital admissions and queried the physician for a MCC and CC, not materializing in increased reimbursement when all is said and done.  Undoubtedly, this is a not a good use of resources for the hospital. Consistent ongoing queries for documentation specificity in type of heart failure and degree to chronic renal failure is an indication that CDI programs may not be achieving their potential, treating physicians as “participants” in our long standing CDI initiatives rather than the more preferred and beneficial “engagement “ of physicians.  My experience over the course of fifteen plus years in the CDI arena has unquestionably reinforced my belief that a satisfied physician is an engaged physician. Most physicians are disenfranchised with the whole process of documentation, frustrated by the time constraints, challenges and amount of work entailed in recording and communicating patient care to all healthcare stakeholders. Previously in a post here, I pointed out a 10 minute presentation geared towards physicians I completed that was posted on QuantiaMD in February titled Fundamentals of Clinical Documentation.  Take a moment to listen to the presentation at if you have not previously done so.  You will need to register to become a member at no costs, takes about 3 minutes and do search under my name. This presentation was showcased and promoted last week to QuantiaMD members and I agreed to respond to all physician questions posted on the website. Little did I know that over 35 questions were posed by physicians centering on achieving best practices in clinical documentation. One physician posed a question on how best to reflect the potential diagnoses he comes up within his assessment in the H & P besides “rule out.” My response included consideration of listing the patient’s symptom(s) and documenting diagnoses as “provisional,” “differential diagnosis,” or “diagnostic considerations.”  I highly encourage you to take a look at the questions and comments posed by these physicians and arrive at your own conclusion as to revising and revamping our current CDI efforts and energies. Clearly, our present clinical documentation improvement initiatives are not completely meeting the needs of our physician partners in CDI.

Let me close by posing some questions and thoughts for your consideration in an effort to drive an open discussion on this blog as to what path CDI should be taking to develop a “revised” and “revamped” service line as we come to reality that present CDI efforts as we come to know and recognize have ultimately reached its service life.

  • What role does CDI play in insuring a complete, accurate and effective History and Physical reflective of the patient’s true clinical picture aside from reporting of diagnoses
  • What role does CDI play in conjunction with case management in assisting physicians determine patient designation type through effective clinical documentation that best captures the physician’s clinical judgement, medical decision making and thought processes, i.e., what is the physician thinking, where is he now and where is he going with the patient’s plan of care
  • What role does CDI play in promoting consistent and concise progress notes, progress notes that truly show and describe the patient’s clinical progress versus cut and paste and carry forward documentation that is rampant in the medical record
  • What role does CDI have in explaining and detailing the detriments of cut and paste documentation related to patient safety, communication of patient care, significant compliance issues and ability to report patient clinical stability supportive of the physician’s clinical judgment for initiating a discharge order with chosen discharge plan that is safe and conducive to avoiding cost prohibitive readmissions
  • What role does CDI have in reviewing and insuring the discharge summaries are complete, are not a basic rehash and/or virtual cut and paste of the History and Physical, and meet the established standards of discharge summaries by the Joint Commission and National Quality Forum
  • What role does CDI have in working with the increasing number of medical scribes utilized in the Emergency Room as well as hospital medicine to insure complete, accurate and effective documentation reflective of the patient care provided by the physician
  • What role does CDI have in identifying and making the case for solutions such as mobile apps that interface with the EHRs to dramatically enhance the physician’s ability to effectively attain and achieve documentation excellence while improving our overall clinical effectiveness and efficiency in driving meaningful behavioral change in physician’s patterns of clinical documentation

I am most interested in your comments and suggestions. Let’s get an active dialogue going.