CDI’s present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness and effectiveness of medical record documentation. Common KPIs include number of physician queries left, number of queries responded to by the physician, number of queries responded to by the physician that captured a CC or MCC, number of queries responded to by the physician that impacted severity of illness/risk of mortality, number of charts opened and reviewed per day, etc. Examining each KPI individually as well as collectively clearly demonstrate a lack of correlation with measurable improvement in clinical documentation that best communicates the patient care provided. Measurable improvement in clinical documentation adheres to principles outlined in the American College of Physician’s Position Paper-Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper published in January of 2015. Take note of just some of the many credible points made in the article that speak to documentation:
· The medical record was first used by physicians to record their findings and actions and as a vehicle to
communicate with other physicians who might care for the patient in the future.
· The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes
through enhanced communication.
· The clinical record should include the patient's story in as much detail as is required to retell the story.
Current CDI Processes-The Necessity for Reengineering
I submit to you that current processes of CDI focusing primarily upon the capture of CCs/MCCs and principal diagnosis optimization fails to address and achieve in any reasonable manner the purpose of clinical documentation as spelled out in the ACP’s Position Statement. As I have always maintained and still champion, reported diagnoses in the record must be surrounded and supported by accurate reporting and reflection of the clinical facts, clinical information and context of the particular case. This means an accurate and complete History & Physical explaining the circumstances of admission to the hospital including a concise yet encompassing History of Present Illness, Patient Chief Complaint in his/her own words, a physical exam congruent with the patient’s nature of presenting problem and the physician’s clinical judgment, a discussion of any abnormal lab values/diagnostic workup results and other pertinent findings and their relationship to the diagnosis outlined in the assessment, and a plan of care congruent with the assessment. Clinical judgment, defined by the physician’s assessment of a particular clinical scenario and the initiation of action congruent with the assessment, is fundamental to the practice of medicine and must be clear in the documentation.
Progress notes are another problematic area where CDI should be focusing its efforts and energy as well beyond mere diagnosis capture that only impacts reimbursement. We are all too familiar with progress notes that lack purpose, substance and validity with the rampant indiscriminate use of cut and paste and carry forwards. Incorrect and inaccurate information is perpetuated throughout the record with questionable contextual consistency. CDI should be promoting, educating, advocating for and achieving progress notes that meet the following conceptual characteristics: