An elderly man is admitted to the hospital, diagnosed with urosepsis, an outdated but still commonly used clinical term for a urinary tract infection. The patient was actually septic and moved to the ICU, where he receives five days of resource-intensive treatment for renal failure complicated by other co-morbidities. Despite extensive ICU charting, the official record shows the patient died from a localized infection because the initial clinical picture was not clarified with the health care provider.
Upon review, two problems become apparent. First, during the episode of care, the clinical picture and treatment plan should have been clarified with the provider to reflect the patient’s accurate level of acuity. Second is the widening language gap between physicians’ clinical terminology and the coding professionals’ continually evolving technical vocabulary.
The effects of this documentation divide are incorrect reimbursements and lower scores in important quality indicators such as hospital-acquired conditions, severity of illness (SOI), length of stay and others. Almost without exception, a language gap in documentation becomes a quality gap in aggregated data.
This is where an effective clinical documentation improvement (CDI) program comes in.
“Too often, administrators and physicians wonder why their health systems score poorly in publically reported quality measures when they know that great care has been given,” said Aman Sabharwal, MD, MHA, CPHM, senior principal, clinical advisory solutions at Vizient. “CDI is a concurrent approach to working with clinicians to ensure patient records correctly reflect good medical decision-making and quality care.”
A concurrent approach to quality assurance
CDI is designed to catch what could be lost in translation before the disparity creates a problem. This is done through timely chart reviews by clinical documentation specialists, ensuring that the patient record facilitates key coding and regulatory language documentation. Procedurally, CDI also looks at details of a case such as the DRG and asks, 'Is the appropriate DRG selected and are all comorbidities correctly documented?'
“Clinical documentation specialists — traditionally nurses by background — look at what the doctor is writing, what the treatment plan is, and then they match that information with current coding and regulatory guidelines,” said Sabharwal. “CDI is not about how much is written, but what is written. Having pages and pages of notes doesn’t mean that verbiage can be correctly extrapolated to a code, to a bill and to your publicly reported quality data.”
With CDI, people are held accountable for documenting what comorbidities are present on admission as well as other patient safety indicators. It establishes quality checks on processes and procedures that lead to performance improvement.
For time-crunched physicians and clinical staff, CDI’s importance may not be fully appreciated. Their time is already compressed. Being asked to review charts or change methods of documenting may be viewed negatively.
“They need to understand why CDI is important in order to support the program. Start with the evidence; show them the data and the gap analysis. Logically, it is hard to refute - imprecise charting leads to incorrect coding, reimbursement and quality metrics,” said Sabharwal.
Focus on one CDI goal at a time
With numerous CDI program implementations under his belt, Sabharwal understands the wide range of needs hospitals have in this key area and the steps required to improve. “You can’t manage what you don’t measure. That’s why it’s critical for a health system to agree on goals for its CDI program.”
He offered four goals to consider:
- Accurately reflect your hospital’s SOI and risk of mortality
- Improve the profiles of your hospital and physicians
- Accurately reflect your case mix index (CMI)
Sabharwal said a health system often benefits from taking a step back and first determining where to focus its CDI resources. “Administrators will see the value of concentrating on one goal and demonstrating success, then expanding into another area.”
For example, if you wanted to work on the first goal, you could allocate enough trained clinical documentation specialists to review a large payor, so you can measure and manage the success of the program and ensure sustainability. These specialists would focus on core CDI issues, such as ensuring the DRG is managed, as necessary, during a patient’s stay to reflect the accurate acuity level, and all comorbidities and present-on-admission diagnoses are documented.
Sabharwal noted that the work of improving the quality profiles of your hospital and physicians and accurately reflecting your CMI will require more clinical documentation resources. These detailed, time-intensive goals are most efficiently undertaken with sufficient resources in place.
“Clinical documentation improvement is really a quality-of-care initiative. It’s about working with the health care providers to ensure that their documentation shows medical decision-making that accurately reflects acuity and complexity of care, severity of illness, and risk of mortality, said Sabharwal. “Accurately documenting the severity of medical conditions is instrumental in generating better outcomes for the organization.”