We often hear from providers about the seemingly endless number of queries they have to contend with. Nowadays they feel pulled in many directions. How can CDI staff help assuage the overwhelmed provider to make their engagement with the CDI program a win-win for everyone?
The most important thing in the success of a CDI program is provider buy in. In order to keep them engaged, a CDI specialist needs to appeal to their senses of clinical accuracy and data integrity. All quality measures—including morbidity/mortality, patient safety indicators, complications, etc.—are riding on the type of severity of illness captured in provider documentation. If true severity of illness is not captured, it looks like the providers are doing a poor job.
An evidence-base query/clarification can help. The CDI specialists should not be asking questions just for the sake of asking questions (high query rates with no real capture of severity of illness is counter productive). Queries have to make sense. The provider has to have a clue as to what he or she is being asked. It would be senseless to ask for the heart failure type (systolic/diastolic) without the echocardiographic findings, for example.
By ensuring that queries are clinically significant, you will keep the providers engaged. Clinical parameters/definitions are not infallible. They are like mile-markers on the pathway to a diagnosis. There are many things that will satisfy diagnostic criteria, but do not really make the diagnosis. For example, one of the things that differentiates massive pulmonary embolism from sub-massive and low-risk PEs is the presence of hypotension. But if the hypotension is caused by a different source (e.g., hypovolemia, medication, etc.), then it does not meet the requirements for a diagnosis of massive pulmonary embolism.
The same goes for the two out four SIRS/Sepsis criteria. patients with many types of infections may satisfy two of the four criteria (e.g., fever and leukocytosis) but are not septic. The provider needs to determine if the patient’s signs and symptoms are beyond what is expected in a localized infection. The presence of systemic manifestation that cannot be explained by the localized infection (or any other etiology) but now truly represents a toxic immune system response is what makes the diagnosis of sepsis. It is common to find elderly nursing home patients referred to the ED for altered mental state, hypotension, and found to have delirium due to a urinary track infection. That patient isn’t really septic. If rehydration corrects the mental status and the hypotension then what the patient truly had was hypovolemia (dehydration) with some UTI and nothing more.
If you approach the provider with waht is documented in the chart and ask what they actually mean, you will get a better understanding of what is truly going on in the case. Keep an open mind to learning, and ask your questions in a way that provider has some idea of how to answer it. In some cases, that’s easy and clear. In others, the potential answers are not intuitive at all and some guidance is needed. The providers may not know or fully understand what’s happening at the outset. But the real story will come out, and that’s what CDI is all about.
Editor’s Note: Limjoco has more than 25 years of experience as a consultant with expertise in the capture of severity of illness in clinical documentation. Since 2005, he has served as Vice President of Clinical Services of DCBA, Inc., performing coding and clinical documentation assessments and implementing, maintaining, and revamping CDI programs. This article originally published in the DCBA, Inc. enewsletter CDI Talk.
By Kelli Estes, RN, CCDS
Well-meaning CDI specialists that wait too long to initiate a concurrent query may end up missing an opportunity to capture valuable information. I’ve encountered several CDI specialists who opted to wait and see if the provider documents more specificity on his/her own. I appreciate the logic of not wanting to burden providers if not absolutely necessary. However, physicians often appreciate the query as a prompt to remind them to include more specific information in their daily notes. This is especially true when trying to capture chronic conditions that are not going away and may not be the focus of acute care treatment during the inpatient stay. These conditions are very important to capture as they do have an impact on resource utilization, risk of mortality, and length of stay.
Wait too long and you delayed query fro resolved conditions such as acute respiratory failure seems silly to providers and you’ve lost their trust. Wait too long for the provider to document on his/her own and you’ve lost an opportunity to capture documentation improvements concurrently. Wait too long and coders end up querying retrospectively (and then what’s the point of the CDI program?). Wait too long and medical record gets coded and billed as is without clarification.
Alternatively, early queries serve as educational opportunities and documentation reminders for providers.
Interestingly, CDI specialists who usually wait longer to query seem have established programs yet continue to wrestle with provider buy-in. These programs are falling short. The CDI specialists has a very important role in the day-to-day practice of providers. Physicians need to understand the value of a good CDI program and CDI specialists should not be afraid do their jobs–promoting CDI and querying with a sense of confidence.
CDI specialists should explain to providers the reason why queries are issued, making sure the CDI message comes from a place that fosters a positive perspective. The majority of people will respond positively when they understand the “why” behind whatever requests are being made. Always, CDI specialists should communicate with their docs!
Editor’s Note: Estes is a 1993 graduate from Eastern Kentucky University and has over 18 years of experience as a registered nurse in multiple clinical areas. Additionally, Estes has spent over a decade as a clinical documentation specialist and consultant with DCBA, Inc., in Atlanta, Georgia. Since joining DCBA in 2005, Estes has assisted with project management in well over a dozen CDI program implementations across the country to include hospitals as small as 200 beds up to large teaching hospitals. This article was originally published in the DCBA enewsletter CDI Talk.
By Cesar Limjoco, MD
There has been a lot of controversy on whether diagnoses in the emergency department (ED) are true and codeable or just hyped up worst-case scenarios. Many hospitals have created policies requiring the attending provider confirm/document them. Historically, ED providers didn’t realize how important it is to capture an anticipated diagnosis. Instead, they honed in on, first and foremost, taking care of patients and completing their T-sheets so the appropriate evaluation and management (E/M) levels get captured.
CDI programs need to expand their educational outreach to the ED providers because a number of diagnoses that have critical severity are stabilized in the ED. When the patient gets transported up to the critical care unit, the critical conditions may already be stable and not apparent to the attending providers and consultants. If you ask these latter providers to confirm the diagnoses, they may not be willing to do so simply because they were not there in the ED to verify the conditions. Thus, there will be true severity of illness conditions that fall through the cracks and are not captured. Additionally, “suspected” diagnoses or “differential” diagnoses need to be worked up further by the attending providers up on the floor. How do you know which diagnosis is true and which one still needs further workup? A true conundrum.
Let’s examine several true life scenarios:
- A patient arrives by ambulance in septic shock. The physician critically manages the condition with volume and vasopressors. The patient is stabilized and then sent up to ICU. In the ICU, the patient’s blood pressures return to baseline. Will the septic shock be documented by the intensivist and attending provider? Or, just the sepsis? The septic shock is a circulatory (end organ) system failure that pushes this patient’s mortality risk to 65% (as opposed to only 10% with no end organ failure).
- How about a patient with known chronic systolic failure who presents to the ED in acute respiratory distress with significant hypoxia and is placed on bipap. The patient is stabilized and sent upstairs. Will the providers capture only the acute on chronic systolic left ventricle heart failure and not pick up the acute respiratory failure?
- A patient arrives with alteration of mental status and after workup in the ED is deemed to be due to metabolic encephalopathy from sepsis (and not from dehydration because intravenous hydration did not produce any mental status changes). It takes a while for the patient to get up to ICU and when the patient is transferred is now back to baseline mental status.
Patients do present themselves in acute conditions in the ED, get stabilized and are admitted to a hospital unit. In these instances, the ED encounter is combined with the acute inpatient care and become one encounter.
CDI pograms should invest in education sessions in the regularly scheduled ED provider meetings and present actual case studies to ensure capture of true clinical conditions. Continuity in the thought process and documentation of providers throughout the hospital episode is crucial. Is a condition ruled in, ruled out, improving or resolved? When healthcare providers document these descriptors, it makes it clear to everyone of the accuracy of the diagnosis(es).
Editor’s Note: Limjoco has more than 25 years of experience as a consultant with expertise in the capture of severity of illness in clinical documentation. Since 2005, he has served as Vice President of Clinical Services of DCBA, Inc., performing coding and clinical documentation assessments and implementing, maintaining, and revamping CDI programs. This article originally published in the DCBA, Inc. enewsletter CDI Talk
By Rachel Mack, MSN, RN, CCDS, CDIP
CDI Educator for SCL Health
“Let it go, let it go
That perfect girl is gone
Here I stand In the light of day
Let the storm rage on
The cold never bothered me anyway.”
-Disney’s Frozen, 2014
It’s very unfortunate that some of the best learning experiences are the most difficult to go through. I have been fortunate enough to be the SCL Health CDI Educator for approximately one year. We are like many programs in that we are going through – how shall we say – growing pains. Our director was hired on in April of 2013 as the leader to systemize our seven hospitals into one svelte CDI program that previously had no real vision, policies, or productivity standards. Needless to say it’s been a difficult couple of years. In her first year my director had to terminate two employees that were not good matches for our CDI program and were not meeting beginner-level CDI metrics. She shared that it was one of the most challenging things she ever had to do.
Circle now to 2015. Our program has a dedicated educator—me. We have a stream-lined interview process. I’ve created an orientation manual. I’ve trained two very successful CDI specialists who are reviewing and querying at a high level and really “get” CDI (you CDI folks know exactly what I mean). We’re on fire and almost fully staffed. We also have a third new staff member who arrived with several years’ experience.
Unfortunately, I noticed early on that this experience wasn’t as intensive as we’d hoped. She never used an encoder. She didn’t read records thoroughly. She couldn’t identify chronic respiratory failure in a COPD patient. Or acute renal failure in a septic patient. She didn’t know how to perform a follow-up review. She had never heard of Guillain-Barre syndrome.
I began internally panicking. “What am I doing wrong?” “What do I tell my boss?” Then the positive, glass-half-full side of me kicks in. “Everything is fine!” “She’ll get it!” “It will all work out!”
And I chose to ignore some glaringly obvious signs that this person was not a good fit for the job.
Then our CDI team lead at her site shadowed her for several days, and reported back to me the same findings. She missed an easy encephalopathy query. She had sepsis in her notes, but not in the encoder. She had shortness of breath as a principal when congestive heart failure was clearly documented as the cause. The CDI team lead asked me if I’d noticed any of this.
More panic. And sweating. I was so terrified of failure—and the vulnerability that brings—that I wasted several weeks of this person’s time, as well as my own time, and our team lead’s time. All because of my horrifying fear of failure.
I finally confronted our CDI compliance and quality analyst to discuss the situation and explain that this was not a good match and, in my opinion, we may need to start taking the steps to move her out of CDI. With her direction and the help of my director that was the decision we made.
That was the easy part. Now comes the actual conversation: “You’re not performing well. I’m not sure your experience matches what we were looking for. You’re not a good fit for this role.”
I had never had to have this conversation with an employee. With my heart racing and my stomach in knots I laid out all of the (very well-prepared) points I needed to make.
Then she cried.
I choked back tears, conveyed empathy, but stood my ground—the role of a CDI specialist is too important to not have the best people doing it. One of our facility’s core values is stewardship—we are entrusted with the resources provided to us. And when the CDI role is not well-matched, it can be a recipe for disaster.
I went home feeling terrible. I wanted to feel good and like I did the right thing. But I felt terrible.
The next day, however, she came in and said “thank you” for my honesty. I was shocked and humbled.
What I took away from this experience is this—the worst things are occasionally the best things for us. This experience forced me to get creative along the way—I made more educational pieces and improvements for the orientation manual. It increased my ability to be patient and have empathy with others. It taught me to trust my gut and confront problems before they spiral out of control.
Thomas Edison said, “I have not failed. I’ve just found 10,000 ways that won’t work.” Cheers to failure. Hopefully less than 10,000 for all of you. I quoted the movie Frozen because I truly hope the storm rages on. Bring on the failure—the cold never bothered me anyway.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’ve pulled from the fourth annual Clinical Documentation Improvement Week, in which Karen Chase, RNC, BSN, Assistant Director of Clinical Documentation Improvement at Stony Brook University Hospital in Long Island, New York, a 603-bed academic medical center, answers questions regarding program monitoring.
Q: Does your CDI department audit for query accuracy and compliance? If yes, can you describe your process?
A: Yes, but what I do is a manual process at this point. Unfortunately the only program we have is basic, with no computer assisted coding or query program. Everything is sent through e-mail and the staff CC me on all emails. I pick 10 queries per month for each CDI reviewer, pull the chart, and see if they are leading, appropriate, or if anything was missed. I also look to see if the chart was reviewed an appropriate number of times. I look to see:
- Was the working DRG appropriate?
- What was the CC/MCC capture rates for that CDI for that week?
It’s not the best way, but I’m not automated yet. We moved to an electronic health record two years ago, about six months after I started, and we are hoping to get a 3M program approved in the near future.
Q:What quality metric does your hospital administration find most helpful/compelling when evaluating the success of your CDI department?
A: In the beginning we tracked the case mix index and saw tremendous increases. But then we became stagnant and had to find other ways to measure our progress. Now we use mortality index, also CC/MCC capture rates by service line. We also take DRGs with triplets and compare quarter to quarter how many have CCs, MCCs, or no CC/MCC, such as DRGs 245-247, 280-282, etc. I have a dashboard with those metrics I show administration.
One of our improvements [last] winter was pneumonia (DRGs 193-195). Through documentation improvement, we brought our MCC capture rate from 19% last year to 27%. We also share success with Patient Safety Indicators (PSI). We also look at quality metrics—core measures metrics like aspirin on arrival—and try to help out our quality department in any way we can. We alert quality when there is a quality issue.
For example, if something flags as a PSI, they give it to me, our [CDI] people review it, and if it’s a documentation issue we can fix and query. If not, I toss it over to quality. Even though quality and CDI are separate, we work well together.
We also do mortality reviews. If a patient dies, I get that chart, we get it coded, and we have an ICU nurse who reviews them for documentation improvement. If she sees something that is a quality of care issue, it goes to the quality department. Quality does more retrospective reviews and we do more realtime reviews and we can pick things up faster with our concurrent reviews.
by Kelli Estes, RN, CCDS
Any leadership book you read will quickly point out the importance of serving others! Who can we include as likely candidates for the CDI Team to serve? All healthcare providers: Physicians, nurse practitioners, physician assistants, coders, any variety of others.
Unfortunately, the idea of going above and beyond the proverbial call of duty to serve providers is often lost. I have worked in numerous hospitals where the CDI team exhibits heightened frustration over the lack of provider participation in the CDI program, and over the continued poor documentation that results. CDI team feels forced to find a way to work around this group of difficult providers in order to obtain the improved documentation, in the end, from another provider on the case. This tends to give a “pass” to certain providers who have the tendency to discount the importance of CDI compliance. sually this results in an incessant flow of behind closed door mouthing without ever obtaining a workable solution for the future. Sadly, this only sets the table for a negative attitude toward the group of difficult providers.
So what is the CDI Team to do? First, maintain the proper perspective!
Any well-oiled machine has all the moving parts working together at the appropriate time. CDI can be a very complex process that involves input from several different parties to get it all right. Undeniably, everyone has to own their part, but it would behoove any CDI team to provide whatever is necessary to encourage the providers to incorporate CDI into their busy and demanding schedules.
Before you “boo” this entire idea, think about those providers who require repeated queries for the same things, over and over. Most often when I ask CDI specialists if these providers answer their queries, the answer is yes. I remind them that this is still a “win” for the CDI team. Remember why the CDI team is in place. Undoubtedly, the vast majority of providers will begin to document certain conditions unprompted; however, don’t become discouraged when some providers require ongoing CDI queries; that is precisely why CDI is so valuable to the overall continuity of improved documentation.
Secondly, talk to the providers! Taking the initiative to set up a time to talk with difficult providers and explain the “why” behind your need for clarifying queries is a necessary step to facilitate CDI participation. Physicians often get saturated with a great deal of information when CDI programs are first implemented then fail to hear much else beyond that point. Ask providers how you can better serve them in future CDI efforts. Do everything you can to help them realize that you are there to help and be a credible resource for their future documentation improvement needs. Express your willingness to cater to their individual requests within reason. This will allow the difficult providers to recognize that the CDI team can help improve their documentation without completely disrupting their day.
Nevertheless, you may continue to face some barriers such as:
- The CDI specialist (or team) does not understand a disease process well enough to discuss the need for clarification with confidence.
- There is a lack of administrative support for fostering a collaborative relationship between the CDI program and providers regarding CDI initiatives.
- There is no CDI physician liaison in place.
If any of these are the case at your facility, consider the following:
- Employ the CDI team member most knowledgeable about a particular disease process when discussing with a provider. Allow a newer CDI staff to come along for the conversation and be mentored.
- Provide case studies to administration that demonstrate the positive effects of provider participation.
- Provide other case studies that support the need for a physician liaison. In the meantime, use physicians with whom the CDI staff have a great relationship to discuss difficult cases prior to approaching providers.
Despite our best efforts, we will never completely rid ourselves of those challenges presented by difficult providers, but maintaining an attitude of serving the providers will always prove to be a successful approach to gaining a win for the CDI program.
Editor’s Note: Estes has spent more than a decade as a CDI specialist and consultant, presently with DCBA Inc., in Atlanta. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. Contact her at firstname.lastname@example.org.
Q: I understand that most CDI departments develop a standardized list of clinical indicators/criteria to support query efforts. Is this something we need to develop or is it available in the encoder process? If we need to develop this, how do we go about that?
A: While the AHA’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS) often lists clinical indicators for specific diagnoses, the publication should not be used as a stand-in for the provider’s own clinical judgment, as reiterated in Coding Clinic, First Quarter, 2014, p. 11.
CDI programs should work with the physician team to develop a standardized list of clinical indicators for the team to use in query creation, CDI and physician training, and record review. Such mutually developed criteria is particularly helpful for highly vulnerable or often miss-documented conditions such as levels of malnutrition severity, acute and chronic respiratory failure, acute kidney injury, encephalopathy, etc.
Research nationally established guidelines for these common, core conditions (e.g., ASPEN criteria for malnutrition, or RIFLE or NKIDO criteria for renal failure), then work with the specialty most closely related to that diagnosis (e.g., pulmonologists for acute respiratory failure). This criteria could then be consistently used by CDI and coding staff to initiate a query to support the diagnosis.
Editor’s Note: This article was originally published in CDI Monthly, by DCBA, Inc., and shared on the social media network LinkedIn. It has been adapted from its original and is republished here at the invitation and permission of the author and participants.
“Many CDI programs have set as their goals: accurate coding, maximum reimbursement, increased case mix index (CMI) and better risk-adjusted scores,” says Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc. in Atlanta, Georgia.
“But are they missing the mark? Are they setting their targets low and setting themselves up for a fall?” Limjoco asks. “The goal sets the tone for one’s actions. The end justifies the means.”
CDI programs with preset agendas can slip into focusing solely on those priorities at the expense of the clinical truth, he warns. Like a racehorse wearing blinders to limit distractions, CDI specialists can be blinded to all but the racetrack before them. Without a broad perspective they may have a tendency to arrive at incorrect conclusions, he says. For example, if these end goals take precedence it becomes easier to see (and query for) a variety of diagnoses that may not be true given the entire picture of the patient’s condition, Limjoco says.
“As you may have heard before, medicine is both an art and a science. A provider does not come up with a diagnosis just from laboratory and other workup. There are false positive and false negative results. The provider has to marry the workup results with the clinical picture of the patient,” he says.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Pediatric efforts offer new CDI opportunities” which originally published in the October 2013 edition.
“We’re seeing more and more children’s facilities starting CDI efforts,” says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. “The largest growth comes from multi-hospital systems that already have CDI programs in place. They see the potential of expanding to their affiliated children’s facility.”
With roughly 500 children’s facilities in the nation, Gold sees both the probable benefit and difficulty inherent in such CDI expansion. Children’s hospitals do not have Medicare patients—the typical starting point for traditional, short-term acute care hospitals, he says. In fact, most are paid on a contract basis related to a certain percentage of the actual charges of the care provided “so there was little financial incentive for children’s facilities to implement CDI,” he says.
At the Medical University of South Carolina (MUSC) in Charleston, Karen Bridgeman, MSN, RN, CCDS, CDI specialist, started building the case for expansion by examining data from the University HealthSystem Consortium and National Association of Children’s Hospitals and Related Institutions. This data allowed MUSC to compare benchmarks regarding patients’ severity, mortality, and facility case-mix index (CMI). They took the 25 top and bottom DRGs and divided them into two categories—high-volume, low reimbursement and low-volume, high reimbursement—for Medicaid, Blue Cross, and commercial payers.
The data suggested that a higher level of clinical complexity existed than was being depicted in the medical record, Bridgeman says. Asthma and bronchitis, seizures, and neonatal care fell into the high-volume, low yield bucket; that cardiothoracic conditions and Level III neonatal ICU fell into the high-yield, low volume bucket; and that chart review of pediatric patients could help with respiratory failure, cystic fibrosis, sickle cell, and chemotherapy documentation improvement.
“We found the physicians writing respiratory distress, but that just wasn’t clear enough to determine whether it was an shortness of breath or a respiratory failure,” Bridgeman says. “Sepsis and shock weren’t being documented at all.”
Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal diagnoses and also top diagnoses for our system. We are a home-grown program, about three years old now. Our team made $6 million last year. I know there are many query opportunities and ideas for program expansion but how do we find the right areas for our facility?
A: I am unaware of any industry standards that identifies a timeline of expectations for a plateau of reimbursement/physician documentation improvement. If you have a relatively stable medical staff with few changes, the program should mature and demonstrate physician documentation improvement more quickly than an organization that experiences high turnover of physicians, such as a university or teaching hospital. A teaching hospital may never plateau as the influx of residents and the constant rotation among specialties means educating physicians and capturing the “low hanging fruit” never ends. Each organization will have their own rate of turnover and educational needs for medical staff.
Such programs would have a lower query rate but maintain increased levels of CC/MCC and severity of illness/risk of mortality (SOI/ROM) capture. In other words, the physicians have retained and applied the education, they require less questioning but their documentation supports higher reimbursement levels.
The second variable in this equation is that as a CDI program matures the staff will find “different trees of low-hanging fruit” to pick. At the beginning, you learn to recognize potential documentation opportunities amongst the apples and oranges and begin to see a decrease in queries related to these but you learn there are opportunities in the lemon trees and the mangoes.
Lastly, organizations are constantly adding new services, new procedures and with each change CDI programs may identify entirely new opportunities. In other words, I have not seen in my experience a leveling off but more of an evolving focus as a program matures.
Self-education and participation in CDI networking are important in advancing your own career, your own knowledge, and your CDI program efforts. If you do not currently have tracking systems in place for individual CDI specialists’ and individual physicians’ query behaviors, you may want to. This might identify specific learning needs for individuals that could be targeted. For example, what diagnoses are the CDI specialists querying for? Does one CDI staff member miss sepsis opportunities or are there opportunities the entire team needs to learn about? If there a specific physician that needs intervention on a particular diagnoses?
Most successful CDI programs work closely with their coding teams. Expand on this collaboration by having the coding staff bring forward any trends or difficulties they’re seeing in daily practice. Ask to review any retroactive queries for trends and trouble spots. Identify any documentation improvement opportunities the CDI staff may have missed. The idea being, you and your CDI team won’t miss that opportunity next time.
If you do not have access to your organization’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), seek out access. PEPPER is produced by CMS and it compares your organization to like organizations within your region. It identifies where you maybe an outlier for specific diagnoses and CC/MCC capture. You may be able to identify improvement opportunities in areas where you are a low outlier compared to your peers.
I often found my new fruit by reviewing the code set. Just opening up the code book and seeing what specificity was needed in code assignment for specific diagnoses often demonstrated for me areas of needed improvement. I would suggest doing that with theICD-10-CM code book. You can start asking questions related to ICD- 10 now so that the learning curve will not be so steep come October of next year.
Lastly, an exercise I suggest for new CDIs and one that might require repeating as the definitions do change is to take the list of CC/MCCs and highlight those diagnoses that are often seen within your population. You may find there is a “fruit basket” just sitting there that you never considered. If you identify codes that you have not thought to ask for look them up in the code books and learn what terms are needed to support their documentation. I promise you this effort will bring to light at least one diagnosis common to your population that you might not be capturing on a regular basis.
Wikipedia tells me there are over two thousand different fruits in the world so you have many to harvest!