Take Stock in Your CDI Program-Check Under the Hood
Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have discounted the necessity to evolve with the times, overlooking critical opportunities to contribute to the overall welfare of the healthcare delivery model. A strong CDI program for the right reasons with an underlying commitment to achieving meaningful measureable sustainable recognizable change in documentation patterns is key to a high performing revenue cycle processes. Complacency is a natural byproduct of an organization remaining comfortable with the status quo, mistakenly believing that the organization is attaining value and results from current processes. Often times the organization’s top executives, the decision makers that approve and fund initiatives receive inaccurate, misguided, counterproductive and counterintuitive advice and direction from consulting companies that purport to be “subject matter experts” in their respective fields. Factor in associations that represent their respective industry who promote and perpetuate the continuation of the status quo in webinars, journals, trade shows, conferences, boot camps and radio shows and you have a recipe for ongoing complacency as the norm. Let’s take a deep dive into the current state of affairs of the Clinical Documentation Improvement industry
Current State of Affairs-CDI
The clinical documentation improvement movement in hospitals initially was rooted in “improving” the quality and completeness of documentation in the medical record. Over time, the industry evolved as a means to meet and address head on a quest to “goose” the case-mix index and resulting reimbursement. While I am a firm advocate and proponent for insuring ideal reimbursement given the high costs of providing quality focused outcomes based patient centric care, the methodology employed in present day CDI processes that are thought to define and accomplish documentation improvement are vested in misnomers and misunderstanding of what the medical record actually stands for.
The medical record serves first and foremost as a communication tool for physicians and all other relevant healthcare stakeholders to best serve the patient’s care needs, whether they be acute episodic conditions managed in the hospital and ambulatory care setting or chronic conditions or preventive medicine provided in the ambulatory settings. When the medical record is treated as and thought of primarily as a reimbursement tool that the CDI profession and the cottage industry of consulting companies serving the profession subscribe to and operationalize, complacency and chasing the all might dollar deeply set in. I encourage everyone directly in clinical documentation initiatives to open the hood and take a real hard look at what is actually being accomplished through finite healthcare dollars spent on CDI initiatives. Conduct a sample review of medical records for purposes of assessing the quality and completeness of documentation and draw your own conclusions as to the state of documentation. Effective compliant and accurate documentation is a fleeing notion with the advent of the electronic health records. CDI is accomplishing very l