Guest post: What history tells us about CDI’s future

By Howard Rodenberg, MD, MPH, CCDS

History is a favorite subject of mine (unlike math, read my other post about case mix index and statistics). I firmly believe the adage that those who cannot learn from history are doomed to repeat it. Of course, there is a difference between learning history and understanding it. I can know that America participated in World War I and World War II, but that knowledge does me no good without understanding its context. This is especially true if you’re in an English pub and someone remarks about “those stupid colonials,” it does you no good to say something to the extent of “well, at least we didn’t have to bail you out of the Falklands.” Without understanding the enormity of the British contribution to the war effort, and indeed the role of the British peoples as the first line of defense against the Nazi hordes, that statement might get a beer thrown at you. Or so I’ve heard.

So, what can history tell us about the future of CDI programs? To some extent, that’s a trick question.

Given that CDI has a relatively short track record, there’s nothing there to predict with certainty. But, I do think that history teaches us that successful endeavors often put themselves out of business, which would be the end-result of a truly successful CDI program. Providers would be so well educated, and technology leveraged so successfully that there would be no need for queries or other CDI work. Fortunately for our job security, those days are far ahead of us, and likely aren’t in the cards at all. But, I do think it’s safe to say that as CDI programs mature, we can expect diminishing results, and more difficulty in concretely demonstrating their value.

I say this for a couple of reasons, again drawn from history. First, as programs, industries, or civilizations mature, they come up against some kind of natural limit. History would indicate that as we reach the limit of what’s possible, the opportunities for improvement diminish, the impact of these scarcer opportunities becomes smaller, and the price for each incremental gain is higher. There’s only so much oil and gas left in this world, and no matter how much fracking we do eventually it’s going to be more and more difficult to get that last ounce out of the bedrock.  Successful CDI programs also face the issue of diminishing returns. Even with the most willing physicians, there’s only so much CDI information you can pack into their brains, so many pocket cards they’re willing to carry about, and so many lectures they can assiduously attend. There’s only so much you can document within a three-part DRG group (perhaps more if it’s an APR-DRG with a severity of illness/risk of mortality component, but you get the drift).

And beyond that is biology: While the exact number is different for everyone, going past a certain number of diagnosis becomes incompatible with life. Morbid, yes, but an example of a natural limit.

I think there’s a physiologic model here as well. The case mix index slope of a model CDI program would, I suspect, look a lot like the oxyhemoglobin dissociation curve: Flat on the bottom before oxygen is put into the picture, a steep slope towards saturation once oxygen is there, and then a plateau effect trying to get those last few percentage points from 95 to 100%, requiring higher and higher oxygen concentrations to do so, at higher cost—not just more expense for medical gases, but also the risks of oxygen toxicity and positive-pressure ventilation. Similarly, the CMI starts out low before any CDI effort, shows sharp gains as the program revs up, and then peters out at the top of the curve. It is, in fact, a microcosm of history.

Does this mean that as things get better, we can enhance ourselves out of a job? To some extent, our security is in turnover. That’s especially true in an academic institution, where the residents (a.k.a. “main documenters”) are churned over every year. There’s probably a bit more medical staff stability in the community hospital setting, but probably more intransigence as well that’ll serve to keep our query fingers busy. But, I do think as automation of the query process and data mining for clinical parameters within the electronic health record becomes more prominent, the return on investment of a CDI program may not be quite so clear. 

It’s important to recognize this because, while we see the day-to-day value of our programs, what others see as CDI programs mature is a decreasing impact on CMI, fewer queries with financial gain, and decreasing fears of audit through more secure documentation. It’ll be important to devise a local strategy to focus not so much on where you are, but from whence you came and how things might be without you.

The key is to look at what your CDI program focused on in the past, identify opportunities in the present, and shift priorities for the future without giving up those gains that built your program to the success it is today.

(If you like this kind of stuff, might I recommend Jared Diamond’s book Collapse, and Yael Noel Harris’ book Sapiens. Both are exemplars of the new discipline of Big History. Book club discussion in San Antonio. See you there.)

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.