Effective clinical documentation improvement (CDI) programs make sure a patient's clinical status is accurately represented in the medical record. To do this, Clinical Documentation Specialists (CDS's) and coders work with physicians and the clinical team to identify and correct instances in which a medical record does not sufficiently support the patient's severity of illness, risk of mortality or the care received.
This process is incredibly important, now more than ever, as reimbursement models transition from volume to value. Left unaddressed, inaccurate or incomplete documentation can result in higher incidence of error, financial loss, lower quality scores and compliance issues, among other problems.
To keep clinical documentation vigorous, consistent and timely, many hospitals implemented CDI programs. But most did this approximately 10 years ago and a refresh is in order for many organizations. Becker's Hospital Review caught up with Laura Jacquin, RN, MBA, partner with Chicago-based Prism Healthcare Partners, and Denise Tinkel, RRT, MHA, CCDS, director at Prism Healthcare Partners, both of whom have extensive experience helping hospitals and health systems strengthen their CDI programs.
"We're finding that CDI programs have lost focus or transitioned team members," says Ms. Jacquin. "Many programs are not as robust, accurate or effective as they once were, and CDI programs' staffing and needs often evolve after their initial launch."
Now is an especially bad time to hit a plateau, as there is greater emphasis on CDI since it drives coding, quality profiles and reimbursement. In short: Health systems cannot afford anemic CDI programs, especially under pay-for-performance reimbursement models.
"Documentation in the medical record touches every aspect of the patient's experience," says Ms. Tinkel. "It affects hospital and physician profiling, captures severity of illness and the risk of mortality, and supports length of stay and medical necessity." Further, Ms. Tinkel says complete medical record documentation functions as revenue protection, helping providers defend themselves against RAC audits, insurance denials and even litigation.
In sum, clinical documentation is a significant reflection of the excellent care a hospital and its team delivers to patients daily. How can your organization do it better?
The core components of a high-performing CDI program: People, process, technology
An effective CDI program is dependent on the concerted combination of people, process and technology.
1. People
Executives: An effective CDI program must have an actively involved senior management team, including executive sponsors and key stakeholders to whom the program reports. If that reporting structure is not currently effective, it is necessary to restructure so the right senior leader oversees this critical function. The senior leader to whom a CDI program reports to varies across organizations. "For some, it's the CFO," says Ms. Jacquin. "For other organizations, it's the physician champion or CMO. We've worked in some places where CDI reports up through quality, and in a rare circumstance, to the CIO."
How should organizations decide which role is most appropriate to oversee CDI? Ms. Jacquin recommends determining which senior leader is most passionate and invested in the success of the program.
Physicians: "Physician education and engagement are critical," says Ms. Jacquin. After all, the CDI team works with physicians and their extender colleagues on a daily basis. Hospital leaders can facilitate physician support by appointing a physician or team of physicians to act as CDI champions. Ms. Jacquin has seen positive results from both a team and individual champion arrangement. Physician champions should be motivated to drive change across the facility, have a strong rapport with their physician peers and understand the impact of CDI on patient care and the hospital's bottom line. Finally, senior physician leaders must also be involved. In academic medical centers, specifically, department chairs are highly influential.
CDI team: CDI programs need dynamic CDS's who possess both clinical expertise and coding knowledge. Members of a robust CDI team can come from a range of backgrounds, such as health information management or nursing. HIM professionals or coders are familiar with compliant documentation rules and patient privacy regulations, while nurses have the clinical background to identify gaps in clinical evidence and documentation. Together, these skill sets enable the team to look at a record and determine what's missing. "It's like putting a puzzle together with a missing piece," says Ms. Tinkel. "You need clinical and coding professionals working together, as well as physicians participating fully in the program."
2. Process
Efficient and effective daily work flows allow all aspects of the CDI puzzle to come together. The CDI team needs a process to know which records to review each day, how to best access physicians with questions, and to generate face-to-face interaction with the physicians while they are on the patient care units. These processes push clinical and coding team relationships to the forefront. "You need a process to close or reconcile records, and to do that you need strong, collaborative relationships among the CDI team and the professional coders," says Ms. Tinkel.
The daily documentation and coding processes ultimately make or break compliance and engagement with CDI efforts. "Many times we find staff are so busy, CDI comes second — for physicians especially," says Ms. Jacquin. "A lot of times they say, 'We're too busy, we can't do anything else.' That often means the underlying process is not as smooth as it could be. Effective CDI programs don't necessarily mean adding extra time or steps for the care team," she says.
If leaders hear a similar reaction from physicians, NPs or PAs about CDI, it indicates they may still need to examine the number of CDS's on the team. "They may need to hire more team members," says Ms. Jacquin. "The CDI process is so important and so detailed that hospitals must ensure they have an adequate number of CDS's to cover their organization's specific patient population."
3. Technology
Arming CDS's with the tools and technology to do their jobs effectively and accurately can have a significant impact on efficiency, data quality and proper reimbursement. For example, hospitals can program clinical documentation software and Electronic Health Records to automatically prompt providers for additional information when they enter specific diagnoses, medications or treatments, helping to support the efforts of the CDS's, physicians and coders. "We have helped clients maximize physician participation and engagement in CDI programs through the development of disease-specific prompts in the EHR," notes Ms. Jacquin. "The prompts support physicians in complete and accurate documentation of disease processes and provide guidance for the type of documentation required based on the supporting clinical indicators."
Technology is also vital to capturing the data needed for the robust reporting of program activities that executives rely on to demonstrate the value of CDI and identify additional opportunities. "Hospitals can leverage a variety of technologies and tools to drive data collection," says Ms. Tinkel. "This data is essential to the metrics tracked in comprehensive CDI Departmental and Physician Dashboards that leadership uses to support continual performance improvement and illustrate the impact of CDI on the organization."
Taking stock of your CDI program today
A comprehensive assessment of a hospital's CDI program is necessary at least every year. "It's hard to determine what changes need to be made if there is not a full assessment of the current program on a regular basis, particularly given today’s frequent updates related to coding rules and guidelines," says Ms. Jacquin. The assessment should include review of several metrics, including:
- Patient case mix (should be increasing or holding steady)
- Coverage rate (best practice: greater than 85%)
- Query rate, or how many questions are posed out of the number of records reviewed (best practice: greater than 30%)
- Physician query response rate (best practice: greater than 90%)
- Physician query agreement rate (best practice: greater than 90%)
A note on the last item, physician query agreement rate: A falling rate suggests physicians don't understand the queries, the questions themselves are not effective or physician education efforts need a boost, according to Ms. Tinkel. "Sometimes there are new clinical phrases physicians are picking up and using that don't translate to coding terms," she says.
Prism offers a complimentary CDI Diagnostic Tool to help hospitals understand the potential financial benefit opportunity of revamping their CDI programs.
In addition to assessing the CDI program and educational efforts for physicians, hospital leaders should ensure CDI team members have access to educational resources. As CDI teams experience staffing changes, turnover and industry changes such as ICD-10, there is great opportunity to refresh their collective knowledge and proficiency.