Clinical Documentation Improvement A Fresh Perspective

Clinical documentation improvement programs have evolved over the past ten years with market penetration in most healthcare facilities as hospitals, recognizing and treating these initiatives primarily as revenue enhancement tools. 

The latest trend in clinical documentation improvement is within the outpatient setting, attempting to emulate and duplicate efforts in the inpatient setting using capture of HCC conditions as an outpatient version of inpatient CC/MCCs for purposes of reimbursement enhancement. While I fully support hospitals and health systems realizing and achieving optimal reimbursement for quality focused patient centered cost-effective care, I have always had significant reservations with CDI program's vision and treatment of their programs as first and foremost revenue generators. 

A major limitation of revenue generation achieved through capture of specific diagnoses that drive MS-DRG assignment is the detrimental effect of overlooking and downplaying the larger picture of affecting positive sustainable improvement in clinical documentation, documentation that better serves the patient and physician in the form of effective communication of patient care. Establishment of and adherence to Key Performance Indicators predicated upon generation of queries as processes supportive of reimbursement, accounting to an end, may be viewed as performance without purpose. The number of CC/MCC or HCC conditions captured and reported through the query process bears little, if any, resemblance on the quality and completeness of communication of patient care aside from diagnoses that spring up in the chart like dandelions in the spring in one's lawn. The record contains a diagnosis with often minimal supporting documentation of the clinical facts, clinical information, and context necessary for adequate support and clinical justification of the diagnoses queried for and documented in a History & Physical or progress notes. Clinical indicators appearing in the chart without sufficient clearly depicted and reported facts and clinical information as told and described in the record is quite matter of fact not constituting documentation improvement.

Approaching CDI in a More Effective and Efficient Manner
Success in outcomes is driven by strong well-designed structural foundations and clearly organized integrated processes that produce optimal outcomes with a wide array of appeal for multiple end users. 

Consider a manufacturing process for nails used in different capacities and purposes. Contractors can utilize nails to frame a new house while home-owners may utilize nails to hang pictures on a wall or build a shelf in the garage. 

Now consider the medical record representing the account of an inpatient encounter. Examine the disciplines in the healthcare delivery model that are dependent upon the completeness and accuracy of the medical record to fulfill their duties and responsibilities as stakeholders for the patient. The extent to which the medical record documentation communicates all facets of care delivery from time of presentation to the hospital until the time the patient is treated and discharged governs how well all healthcare stakeholders can carry out and execute their contributing role in patient care. 

Consulting physicians, other hospitalists, case management, utilization review/management, discharge planning and social work, coding, quality, risk and safety, third-party contracting, patient financial services, and business office are all dependent upon a record that adequately and unequivocally tells, describes, shows, tells, depicts, paints, and reflects the patient story from introductory chapter to body and conclusion of the patient story. Diagnoses reporting constitutes only one small portion of the story, the setting of the tone of the story. The plot of the story is essential for readers to gather and relate to the meaning of the story. The same is true of a medical record as a communication tool.

Case Study- A Point to Share
Allow me to share some points and ideas that supported my recent overall successes in guiding an established CDI program from one of traditional processes to one that engaged physicians in wanting to participate and become more fluent and skilled in communicating patient care. By stressing the ability to communicate with enhanced efficiency and effectiveness in fewer words, physicians become motivated and exhibit the desire to learn and become more proficient at documentation.
The following list represents the fundamentals of transforming traditional approaches to CDI of securing diagnoses to a more meaningful approach to securing complete and accurate documentation that is sustainable over time with far less reliance on the query process:

Getting Started-Taking Action
This is certainly not meant to be an exhaustive list in transforming CDI as a process to achieve superb documentation that best facilitates the communication of patient care. Just the same, it serves as a conduit for pointing out the merits of migrating away from the traditional approach to CDI that has reached its useful shelf life and purpose. 

The time is ripe to expand the CDI's purpose, recognizing the immediate need to realize the profession's opportunity to develop and implement processes that produce performance with positive purpose in the form of stellar communication of patient care.

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, is the CEO and Founder of which offers free resources and a monthly newsletter. Glenn is currently the CDI Manager at University Medical Center in Las Vegas.