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Getting the Diagnosis Correct: What's the Impact of HCIT? (Part 1)

May 20, 2012
by Joe Bormel
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Getting the Diagnosis Correct: What's the Impact of HCIT? (Part I)


This past week, I attended a conference and seminar at the center of whether we get MU right or simply pave the cow path.  The conference was conducted by the Association of Clinical Documentation Improvement Specialists (ACDIS), and the seminar was titled “The Physician Advisor's Role in Clinical Documentation and Coding Integrity.”  Check out the site here.     

At the core of our discussions was the concept of producing electronic versions of current, often non-integrated systems with uneven information integrity. 

As a physician, I was trained to think of coding as a downstream process to care that is of little clinical significance.  But, as I learned during the course of the week; I was dead wrong.  Rather than simply polishing the chart, those downstream processes are intended to strengthen it.  And, with the rapid evolution of MU and value care, the focus on clinical documentation integrity is moving upstream, directly to the provider.

I also found that getting the diagnosis correct, whether for coding, clinical care, quality improvement, or value-based payment is straight-forward but not at all simple.  Further, for a variety of reasons including RACs and payment denials, making charts and their stated diagnoses “bullet-proof” is no longer a “nice to have” option. 

Let me provide a common example of something that probably occurs at least once a month, if not more often, at your institution.  Substantially similar things occur every day.  The physician writes “ARI” or “ARF” on the chart, meaning Acute Renal Insufficiency or Failure.  They may even add ARI to the problem list.  However, a relatively simple, established, albeit recent criteria, indicates the patient would be better described by the latter term: Acute Renal Failure. 



Here’s the rub.  At many institutions this sick patient commonly doesn't appear from the chart alone to be nearly as sick as they are because of unfortunate word or acronym choices such as ARI.  Also playing a role may be omissions of references to comorbid, pre-existing diagnoses in their admission history and physical note. 

Traditional documentation was often good enough several decades ago.  Not today.  Unfortunately, in too many instances, modern clinical documentation isn’t sufficiently transparent.  It is now necessary to classify clinical conditions more specifically, especially considering two key factors: the availability of effective treatments for previously lethal conditions; and our aging population, consisting of many who experience multi-organ diseases. 

So, am I making too much of documentation improvement?  I’ll answer this question and more in Part II of this blog.  In the meantime, your comments are most welcome.

Joseph I Bormel, MD, MPH

CMO and Vice President

QuadraMed Corporation

An error doesn't become a mistake until you refuse to correct it.
Orlando A. Battista

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