CDIP at the crossroads

The field of clinical documentation improvement has rapidly expanded into a burgeoning profession with strong potential and long lasting value for all healthcare providers involved in the care of the patient. The importance of and necessity for complete and accurate medical record documentation reflective of true patient acuity, risk of morbidity and mortality, and readmission cannot be over emphasized. There is almost always an opportunity to improve clinical documentation in any medical record chart from both a resource intensive reimbursement standpoint and quality of care and clinical outcomes standpoint.

But just as the profession is gaining momentum and increased recognition in the business facet of healthcare, we have reached a crossroads and may be going down the wrong path.

For those of us who have been in the clinical documentation improvement arena for a long time, it is eye-opening to view the advertisements and promotional materials for clinical documentation improvement projects readily available at trade shows and appearing in prominent trade journals. The common promotional theme is increased reimbursement for the hospital, which is not surprising given the fact these clinical documentation improvement programs are marketed strictly on the basis of “reimbursement enhancement.”

Let’s not kid ourselves, every healthcare expenditure that is not direct patient care related must provide for a reasonable chance of return on investment, contributing to the organization’s financial performance in some for or fashion, whether it be additional revenue or at least cost avoidance. But there has been some talk in the industry that some firms have worked into their CDIP contracts a guarantee of specified amount of increased reimbursement for the hospital with the implementation of their programs. 

The aftermath

Clinical documentation improvement programs can be structured to meet the documentation requirements required in the health record to financially sustain the hospital from a financial accounting and quality of care reporting perspective. How the program is structured can dictate success or failure in the rollout and acceptance of the program by physicians and other ancillary service providers.

In speaking with a fellow colleague recently, I heard a valid concern that is worth mentioning regarding where the CDIS profession is now, and where it may be going. Once again it may be going down the wrong route. My colleague pointed out that in some instances, the clinical documentation improvement specialists appear to be focusing on reviewing the record solely for identification and documentation of “missed CCs and MCCs,” almost as if they were “CC/MCC scroungers.”

The very idea of CDIPs being promoted primarily as reimbursement mechanisms perpetuates and drives the ever-increasing viewpoint of CDIS as CC/MCC identifiers. In order to be directed down the right path, we need to stay attuned to the mission of the profession, which is to affect positive change in physician’s patterns of clinical documentation over the long term through provisions and actions of continued physician education. This relentless pursuit of physician clinical documentation education embraces a holistic approach with an emphasis upon the direct correlation between clinical documentation and the continued business financial viability of the both the hospital as well as the physician. A primary focus upon “getting that CC/MCC” documented in the record represents a very small cross sectional piece of what the CDIS can fundamentally contribute to a successful program.

Looking to the future

A recent article caught my attention, certainly an interesting thought to consider as we are at the crossroad of our profession. Clinical documentation improvement efforts are episodic with a bent toward reviewing individual records and utilizing the clinical query process in striving for complete and accurate clinical documentation. In an article that appeared in the July/August 2009 Journal of Hospital Medicine entitled “Transitions of Care Consensus Policy Statement,” the American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions.

Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. You may read a summary analysis of this policy census statement through this link.  http://hospital-medicine.jwatch.org/cgi/content/full/2009/1009/1?q=etoc_jwhospmed

There are seven consensus principles and standards for managing care transition as follows:

1. Accountability
2. Responsibility
3. Coordination of care
4. Family involvement
5. Communication
6. Timeliness
7. National standards and metrics

While each of these standards embraces elements of clinical documentation, the last standard above speaks greatly for the ability of the clinical documentation improvement specialists to jump into the fray of clinical documentation and fulfill a much needed role of assisting in the formulation and development of standardized communication formats for care transitions that can be used for accountability and continuous quality improvement. Minimal required information in the transition record that the CDIS can help facilitate include principal diagnosis and problem list, medication list reconciliation, identification of the coordinating physician/institution, patient’s cognitive status, and test results and pending test results.

Which way?

We are at the crossroads of our profession in CDI. Which direction we decide to take will guide the ultimate success and future of the profession. Decisions made today will certainly impact all of us tomorrow and well into the future.