Clinical documentation has long been at the heart of any regimen of patient care. An accurate and thorough record of a patient’s health and medical history that includes notes covering all interactions, diagnoses, and treatments gives healthcare providers a quick tool for understanding a patient’s current condition and a powerful tool for determining a path forward. But today, it also can do much more.  

The data once primarily used by frontline healthcare professionals to aid in prescribing and delivering care now also serve as the basis for multiple layers of financial operations, as well as providing input for quality measurement systems.  

Since the late 20th century, the process for clinical documentation has changed dramatically. The clipboard at the end of the bed is long gone, replaced by multiplatform access to electronic health records (EHRs) that give physicians and other care providers immediate and complete patient information.  

Where We Are Now

James-FeeWhen the process of clinical documentation improvement (CDI) came on the scene more than two decades ago, it was a way to help providers bring in additional revenue by making sure they were fully capturing patient conditions, treatments, and outcomes and communicating that information to payers. As the amount of data in EHRs has grown, so has the number of uses to which these data are being applied.  

“The ‘I’ in CDI has become integrity—rather than improvement—because the goal is not so much improving documentation as it is focusing on data integrity,” says James Fee, MD, a practicing physician and the CEO of Enjoin, Collierville, Tenn.  

For example, a diagnosis may be documented as acute respiratory failure, but the clinical picture should support that diagnosis. This concept is increasingly important in the face of denials and compliance issues.  

Some health delivery systems are using software controls to encourage greater specificity in clinical documentation, such as urging clinicians to more carefully note differentials. “Sometimes the documentation is duplicated very easily by the physician using the EHR, and that doesn’t really develop a clear picture of what changes have occurred on that patient that day,” says Autumn Reiter, RN, director of CDI staffing services with TrustHCS. “By shutting off the ‘cut-and-paste’ functions, facilities are seeking to promote a mindset among physicians to write a new and complete note for the day."   Autumn-Reiter

Having that more complete and detailed information enables the CDI specialist to verify the correlation and completeness of various aspects of the documentation. “And it’s essential for the other care providers, as well, because the physician’s notes can tell us what he or she will be testing for and what diagnoses have been ruled in or out,” Reiter says.  

A variety of factors have given CDI a higher profile in recent years.  

“The increasing financial pressure for hospitals along with the need to demonstrate their high quality of care is creating a lot more desire, willingness, and ability to challenge their existing performance,” says Tim Marshall, managing director with Claro Healthcare, Chicago.  

CDI helps improve the reported quality of care for inpatients, but it also is increasingly being understood to be relevant across the care continuum. Although CDI historically was defined as being relevant to the inpatient population, it is equally applicable to other settings. “If you really define CDI as trying to get the record right, then CDI should apply to all your encounters, not just the inpatients,” Marshall says.  

Tim MarshallOne clear example: outpatient care. “If you look at the income statement for a typical hospital, somewhere in the range of half its revenue is coming from outpatient encounters—ED, observation, cath lab, GI lab, and such,” Marshall says. “How can a hospital executive say that, for half of the revenue stream, accuracy and completeness of the medical record don’t matter?”  

CDI is increasingly relevant to new patient populations—pediatrics, behavioral health, rehabilitation encounters, and the like—that historically have rarely had CDI programs. Marshall notes that with changes in payment structures for many of these types of care from a per diem to a performance basis, accuracy and completeness of the medical record for these encounters is now essential, too.  

“We’re also seeing more sophisticated organizations approach CDI in a more holistic way,” Marshall says. “They understand that software alone will not solve their problems. To achieve complete and accurate medical records every time requires people, process, and technology.”  

Where We’re Going

Clinical documentation in general is becoming more accurate, complete, and useful, thanks in no small part to the adoption of ICD-10 and its regular updates. The streamlined process facilitates better communication among the healthcare team as well as making it easier to use the data to uncover trends in the larger population. “ICD-10 was made for data collection," Reiter says. "We can look at similar cases—patient A, who was treated one way, and patient B whose treatment was somewhat different—and ask, how did their length of stay compare? How did the treatment work on those patients? Is there something we could do better?”  

Fee observes that how CDI fits into the operation of health systems is changing. “As health care is changing to different risk-bearing payment models, reimbursement leaders are dependent upon outcome performance. Likewise, CDI continues to have a significant contribution, but it’s changing,” Fee says.  

Evaluating the effectiveness of CDI in terms of financial impact is fairly objective and straightforward. But with the move toward payment for performance, its effect on quality measurements and ratings has become much more important. “The important thing for leadership within a CDI program is to communicate its continued value, because we still are working, overall, within a fee for service structure with a quality attachment to it,” Fee says.  

The current surge in consolidations, mergers, and acquisitions of hospitals and health systems has raised the issue of how to best approach CDI in these situations. Although hospital consolidations in the past typically moved toward standardizing the CDI program, that may not yield the best results.

“Consolidating practices typically results in some level of guaranteed performance,” Marshall says. “It will frequently improve some of the worst-performing hospitals in that system. But standardizing CDI across scores of hospitals typically leaves a lot of remaining opportunity because documentation needs and practices are different from one hospital to the next and from one physician to the next. And trying to apply policies, practices, and initiatives from one part of the country to a different part of the country doesn’t always yield the most effective outcome at the local level.”

What You Need to Know

  • CDI continues to be a mainstay for inpatient revenue as well as providing backup for compliance and prevention of denials.
  • Incorporating CDI into all strategy and finance meetings can help lead to better original documentation.
  • The best CDI solutions are those in which technology is integrated with process.
  • Documentation matters.

Publication Date: Tuesday, May 01, 2018