As noted in Part I of this blog, I learned that as a physician, I had a misconception of the importance and interdependence of complete clinical documentation and coding integrity.  This was made readily apparent during the ACDIS conference and seminar two weeks ago in San Diego.

In essence, when the diagnoses are incomplete or non-specific, bad things happen from documentation subject to interpretation.  Competent doctors may appear to have higher mortality than their actual level because imprecise documentation has made the risk adjustment blind to their truly sicker patients. 

The expected lengths of stay for their patients may similarly paint them as unable to get their patients discharged in a reasonable amount of time, because the expectations are based on inadequate characterizations of their patients’ diagnoses.  Therefore, these physicians can appear to provide relatively poor quality care and to be inefficient, even if they are the most effective and perhaps most caring docs with the best results.  And that's just the direct impact on those doctors.

As a consequence, their organizations will rank poorly in terms of case mix, mortality, and a range of other measures that grow every year as pay-for-performance matures.  Also, their ability to collaborate and coordinate care with other providers will suffer.

Coding is hard enough when the diagnoses accurately capture the patient's situation, but when the diagnoses are non-specific, absent, or wrong, it adds work to everyone's plate.  That’s why Clinical Documentation Improvement (CDI) programs have become such important tools for getting the diagnoses correct. 

As we role out EHRs with the meaningful use measures of up-to-date problem lists, let's elevate the role and responsibilities of those HIM professionals who are trained and credentialed to help the community of providers get the problem lists right.  Their skills are focused on using an important body of knowledge, little known outside the HIM community until recently, to do just that.  This is upstream, concurrent with care and EMR use, and critical to quality measurement, clinical decision support, and at least half of the measures in MU Stage 1 – and likely in the majority of subsequent stages in healthcare modernization.

Specific Recommendations:

1.  Get Yourself Educated:  If you are a physician serving as physician advisor, a C-suite executive (especially CIO and CFO), or an HIM director with less than one FTE per hundred facility beds, you need to attend a conference like the one described here.  Unless you are aware and can comfortably speak to the necessity of a strong CDI program in your facility from any of those roles, any further recommendations are pointless.  This isn’t a topic you can learn by reading about it in a book, blog, or 45 minute inservice.  No one can, for a variety of reasons.

2.  Educate Others:  This is a big topic; in short, it’s an on-going, multi-faceted program.  It ranges from Quarterly staff meetings, one-on-one interactions, and a strong “query” program to communicate and educate in the context of patient care.

3.  Analytics:  There are CDI-specific operational analytics, in addition to traditional metrics like case mix index with appropriate, comparative benchmarks.  And, of course, documentation integrity impacts all other performance measures, including quality and safety.  You need to be collecting, validating, disseminating and trending CDI metrics, as you do with other management information.

4.  Develop CDI workflow for EHR deployment and optimization:  Where and when diagnoses are collected shouldn’t be left to chance, or merely reflect how it was done on paper.  There’s an additional, critical nuance here.  From a CDI perspective, the difference between a comorbidity and a complication can be a matter of when it was documented.  As a result, the admission history and physician exam note, especially the past medical history section, takes on a dramatically heightened importance.   Similarly, the progress notes and discharge documentation carries diagnoses, and their characteristics under CDI requires several hours to adequately elaborate.  Finally, CDI includes related query practices.  All modern EHRs have a variety of messaging systems, including but not limited to inboxes.  Several hours were spent at the CDI conference sharing experiences with how to integrate this component in the workflows involving EHRs.

Although emerging technologies, like speech recognition, computer assisted documentation with coding, and enhanced decision support will play critical roles, our practice of medicine and healthcare delivery will need to evolve and progress as well.

What do you think?