The Association for Clinical Documentation Improvement recently hosted a radio show called the ACDIS Radio Show and the piece was titled “How CDI Must Adapt to Healthcare Reform.” You can listen in to a taped recording of the Radio Show in the near future by clicking on the following link

The radio show started with a survey for attendees to respond to rating  the level of physician buy in for the clinical documentation improvement initiatives at their facilities. Here are the results of the responses as appeared in a blog that was published on the ACDIS website-

CDI success depends on physician support and yet, 68% of poll respondents called support either “poor” (10%) or “fair” (58%), during the February 18 ACDIS Radio program “How CDI must adapt to healthcare reform.”

The poll, which garnered an 85% response rate from the program’s 414 participants, asked “How do you describe the level of physician buy-in into your CDI program?” Additional responses included:

  • 2% Outstanding, our physicians fully understand what is in it for them
  • 25% Very good, most of our physicians are invested in CDI
  • 58% Fair, physicians will respond but often out of obligation
  • 10% Poor, many physicians don’t respond to queries or are disengaged
  • 5% Don’t know/not applicable

Only 27% indicated their confidence in the degree and level of physician buy-in of their overall CDI program. This is quite concerning for two reasons:

  1. At this stage in the game, the majority of CDI programs are mature and have been operational for several years now
  2. Given the longevity of existence of most CDI programs, how can programs continue to operate with “fair” or “poor” buy-in from physicians?

Call to action

Time is of the essence to clearly improve physician engagement. Why? Because good, cost effective patient care, quality outcomes, better care coordination with reduced readmissions, and sustained population health management, all hallmarks of value based performance healthcare models, depends on it.

What can we do to change the situation? We need to change the current CDI model. We need to eliminate perpetual query efforts. We need to understand, and help physicians understand, that complete medical record documentation serves as a communication platform, a tool for the accurate reporting of physician care. This medical record documentation directly benefits all other stakeholders associated with patient care. These stakeholders include other physicians and ancillary care providers, case managers charged with coordinating and advocating for the patient’s care and well-being, physician advisors who fight to insure patient’s receive the proper care in the right setting, post–acute care entities, and most importantly the patient themselves.

We need to work hard to dislodge physicians’ misunderstanding that their medical record documentation is merely a necessary evil in the business of medicine, another burdensome task to be rushed through in an overly busy day. Part of our job as CDI specialists is to convince physicians that solid, effective, complete clinical documentation is just simply good medicine and patient care.

Our message must incorporate the ideal that quality documentation is quality medicine and the two are inarguably inseparable.

Enlisting help

Call in the reinforcements. Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility. If they understand the value of CDI, the value of the complete medical record, they’ll be able to explain it to others. They will carry forth the CDI message and address its importance across healthcare department silos. Unfortunately, some physicians equate our efforts as a front to capture more revenue for the hospital, revenue that does not flow into the physician’s own financial bottom line. It’s a fallacy. And it’s our job to dissuade physicians from this notion. Show them how their documentation improves their quality report cards, their readmission rates, and their own financial outcomes.

Lastly, we need to help of ourselves, our own CDI profession. CDI specialists need to stay informed about the changing landscape of healthcare care reform initiatives and demonstration projects. While many CDI programs began as a way to capture additional diagnoses and improve CC/MCC capture rates, healthcare reform is moving payments away from this model to one based on quality-focused delivery of healthcare. We have a certain amount of responsibility to incorporate this information into our quest for the promotion and avocation of complete, accurate, effective, precise clinical documentation.

CDI specialists can remain true to this quest through our present duties and responsibilities in chart review and ongoing communication with the physicians. The form and message of our day-to-day query efforts directly affects whether physicians will ultimately support our CDI programs. The time is now to take a serious hard look at the message we are carrying. The responses to last week’s ACDIS Radio poll serves as a testament to the need for an updated physician message—one that more clearly reflects the true aim of CDI—to improve the quality of the medical record and capture the most accurate description of the care and services provided.