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Creating a Successful Effective Physician Documentation Improvement Program- Changing Course

March 11, 2018




Creating a Successful Effective Physician Documentation Improvement Program- Changing Course


Clinical documentation improvement has evolved over the last ten years with the advent of the electronic health record and the ability to use natural language processing and other key software to enhance the overall efficiencies and effectiveness of medical record chart reviews. This facilitates the identification of opportunities for diagnoses reporting, hospital acquired conditions and patient safety indicator clarifications. As a whole the profession has not kept up with and adapted to the new age and transformation of the healthcare delivery model with increasing needs for solid, complete, effective and concise clinical documentation that accurately reports and reflects the true care provided. The profession has overlooked the realization that current CDI processes fail to align and integrate with the ongoing changes in the uses of healthcare reported data predicated upon complete and accurate clinical documentation. Let’s take a close look at where CDI is today and what are the key steps to consider in reengineering, reformatting and revamping your present CDI structural processes and outcomes.


Today’s CDI Initiatives


Today’s CDI initiatives for all intensive purposes is focused primarily upon improving diagnoses reporting with the ultimate goal of optimizing reimbursement through DRG Assignment. An additional focus centers upon accurate capture and reflection of data integral to quality reporting measures such as severity of illness/risk of mortality, observed versus expected mortality, risk of readmission, hospital acquired conditions and Patient Safety Indicators. While I would not downplay the importance of these elements and concepts that drive reimbursement in some form and fashion, this unrelenting focus upon diagnoses reporting masks a crucial element devoid in most CDI programs consisting of achievement of valid reliable measurable sustainable documentation improvement. It goes without saying that all CDI programs must be self-sustaining and positive revenue producing in today’s business economic climate cost conscious value-based healthcare delivery models. Value based healthcare can be defined as outcomes as a factor of costs, outcomes divided by costs of care. Looking at a more simplified model of value- based healthcare care consists of providing the right care at the right time for the right reason in the right setting with the right clinical judgment and medical decision making with the right plan of care with the right documentation. Each and everyone of these components that address value-based healthcare delivery are grounded upon the quality of clinical documentation supported explicitly through accurate depiction and reporting of the clinical facts, clinical information and context of the patient encounter. The lack of focus and direction of present day CDI programs upon achieving realizable improvement in the quality of the clinical documentation aside from diagnoses reporting detracts from the practice of medicine i