Guest post: Clinical documentation alchemy: The very modern art of transforming lead to gold

By Nicole Draper, RN, BN, MHA

Formal CDI programs have existed in Australia for almost two years, now. Having established one of the first CDI programs here, I was in a very privileged position to influence how CDI might look in Australia.

I’ve now assisted in establishing several CDI programs in every setting from small regional hospitals to large hospital groups, in both the for-profit and not-for-profit sector. Looking over my experiences, I believe there are 10 key elements that contribute to the success of CDI programs, including:

1. CDI specialist training
2. A patient-centered approach (meaning, all patients, not just those where the revenue will be improved)
3. Physician engagement
4. Physician education
5. Collaborative relationships with clinical coders
6. Recognizing and rewarding clinicians at all levels
7. Continuing education
8. Networking
9. Being present
10. Measuring outcomes

Some background

Fortunately, executive support is a given in this country. In my experience CDI programs are well supported by hospital executives because they understand now more than ever the effect of incomplete and nonspecific clinical documentation from both a financial perspective, and from the perspective of quality and safety implications.

Australia also benefits from the United States’ experience. The programs we’re establishing are focused on quality and safety, ensuring the record is complete for accurate clinical coding and DRG assignment.

There are essentially two different funding models in Australia. First, our public hospitals are funded through the government using activity-based models where the capture of complexity in the medical record through accurate clinical documentation and strong links between diagnoses and treatments results in greater capture of accurate reimbursement. Australia uses version 8 of the DRG in its public hospitals.

The private sector however is somewhat different, with three versions of the DRG in use: 4.2, 5.1 and 6x. Private hospitals obtain reimbursement based on contracts with the health fund, through a case episodic payment model or a per diem payment model. In the per diem model, complexity has no impact from a reimbursement perspective; complexity only affects reimbursement in the case paid environment.

With the two funding models in operation, the message to clinicians is that complete, specific, accurate clinical documentation is important to all our patients not just where the revenue will be improved. In my experience, our success in physician engagement stems from this message. Talking to all clinicians—be they doctors or nurses—the strong, clear message is about ensuring the medical record accurately reflects the complexity of the patient in the bed so the healthcare providers can provide the best care they can.

CDI and clinician education

I firmly believe the CDI specialist needs to be present and seen in the clinical areas. Each opportunity to engage with a clinician represents an opportunity to provide information and education.

In Australia alone there must be more than 1,000 people who have heard me speak about CDI. What I love the most is watching the “light bulb moments,” those moments when people begin to really understand the value in CDI. Like when I talk about documenting the increased clinical care due to a patient’s Parkinson’s disease or how to document for overnight care required for a patient with delirium. Encouraging clinicians to apply coding standards to the way in which we document has been very powerful—during the shift, was there an alteration or commencement of a treatment? Why or why not? What was it due to? Why did you give those antibiotics? Why was the Warfarin withheld? Of course, we are not asking nurses to diagnose patients; however, medications should not be administered unless you know why you’re giving them.

For some clinicians, just knowing that the clinical coders read the medical record in its entirety is enough to make some people try harder with their documentation.

CDI and coder collaboration

A strong collaborative relationship with the coding team can really be what makes a CDI program successful. The coder can ask the CDI specialist for help with clarifying a principle diagnosis or further specificity of a diagnosis. In turn, the CDI specialist gains a great deal of knowledge about coding and coding standards from the clinical coders. 

When each person involved in the CDI process is present and engaged, it ensures the patients’ safety and quality care is at the center. In that case, clinical documentation alchemy is truly achieved.

Editor’s note: Draper is the director of Clinical Documentation Improvement Australia and a doctor of health candidate. She is also one of the leaders of the Australia ACDIS Networking Group. Contact her at Nicole.draper@cdia.com.au. Opinions expressed do not represent a consensus agreement of ACDIS or its Advisory Board.