Guest Post: Why CDI efforts should matter to patients and physicians

by Melinda Tully, MSN, CCDS

For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close.  In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.

Then, starting in 2014, base payments will depend on the outcomes of the care documented.

So how do we shape up before we face even bigger federal cuts?  Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.

I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately.  For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.

Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.

The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true  clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way.  This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.

Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.

For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population.  These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers.  The best part about this customer’s success is they have improved their documentation  and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future.

Physician Profiling
These days everyone gets a report card – not only hospitals, but also the physicians who provide care. One important reason for physicians to improve the accuracy of clinical documentation is to better reflect the severity of patients they treat because this relates to outcomes, mortality rates and patient complications. When records do not reflect the illness of patients treated, doctors skew the accuracy of their reports and may raise concerns when the average patient length of stay (in the hospital) or mortality rates seem too high.  Patients, providers and payers are looking to see how doctors compare and are evaluating physician performance and levels of risk based upon physician profiles.

A good CDI program should give doctors and nurses education, strategies, and tools that allow them to accurately document each case from the moment a patient enters the hospital, assessing documentation real time vs. trying to fix information retrospectively.  One big motivator behind the push towards CDI is ICD-10 regulations.  Many doctors and hospitals are not happy about ICD-10 and increasingly complex demands for clinical documentation. No one can change these federal requirements, but we can help them comply with them so everyone wins.

Think of it like going to an accountant for your taxes. No one expects doctors to remember all the rules and nuances of ICD-10, but we can make CDI and compliance with regulations easier and relevant by customizing CDI for their medical specialty. Peer-to-peer education, tailored specifically to each individual physician practice, can help. For example, the documentation and workflow needs of a cardiologist would differentiate from the needs of an orthopedist, and so on.

This customized approach to CDI simplifies complex requirements for physicians and helps to earn their support early in the process  so everyone wins.  Improving documentation up front while the patient is still being treated is the main goal of CDI because this yields the biggest benefits for the patients, physicians and providers downstream. Now, I know what you’re probably thinking: “Provider benefits? All you’ve discussed is CDI’s impact on patients and physicians.”  Well, stay tuned for my follow up post in January that will dive into that exact topic.

Editor's note: At the time of this article's original release,Tully joined the Nuance team in October 2012 as part of the J. A. Thomas & Associates acquisition. This post originally published on the Nuance blog “For the Health of IT.”