Shari Breuer
Venanzio Arquilla

Hospital clinical documentation improvement programs should move from a focus on payment to a focus on quality and outcomes.

At a Glance  

  • Accurate clinical documentation is necessary for healthcare organizations to achieve quality improvement and accurate payment.  
  • Physician buy-in is essential to a successful clinical documentation improvement program.  
  • The program should not focus on revenue enhancement or a particular tool, but should encourage critical thinking by physicians.  

In today's challenging economy, hospitals and health systems need to build consistent, reliable net revenue streams, and to design measurable processes that enable them to receive accurate payment. Just as important, however, is their need to ensure that clinical documentation accurately reflects the intensity of services provided. Accurate clinical documentation also helps to improve payer negotiations, enhance consumer decision making, and match resources for appropriate care.

Innovative healthcare finance leaders are championing quality and outcomes to their executive teams and physicians. Mark Krieger, vice president and CFO for Barnes-Jewish Hospital, describes this transformation and its impact on healthcare finance: "With the advent of value-based purchasing (VBP), it is a financial imperative that our clinical documentation accurately reflects the condition of our patients and the intensity of care we provide. The final VBP rule was recently released by the Centers for Medicare & Medicaid Services (CMS), and CMS has indicated it expects the reimbursement percentage increase difference between the lowest scoring and highest scoring hospitals will be on the order of 1.8 percent."

Krieger adds: "Beyond the reimbursement rate priority, there is also a longer term risk or reward with volume likely moving to the providers who demonstrate higher quality. Having the most complete and accurate clinical documentation, which indicates the expected patient outcomes, also helps hospitals to accurately set priorities for deploying resources to improve patient outcomes, which is what we are striving to do with every patient every day."

Support for a focus on quality and outcomes begins with strong buy-in from executives and physicians. Then a foundation for success is built upon tools and measurable goals and objectives. Process workflow design and clinical and coding team integration with the physicians is achieved through education that emphasizes a focus on quality. The ownership and involvement of all levels of leadership often influence achieving the desired outcomes. Such executive ownership and involvement establish the program as a priority and support the culture of working as a team with the hospital's medical staff on this important initiative.

The Approach and Hospitals' Response

Using severity-based outcomes to reflect quality of care has gained momentum, especially as CMS focuses on performance and outcomes in an era of healthcare reform. As healthcare organizations implement fully integrated concurrent electronic health records with electronic progress notes, they need to ensure that their clinical documentation processes are addressed appropriately.

When physicians' progress notes are not clear or do not use the diagnostic terms required by CMS, the hospital should request clarification. One of the main goals of clinical documentation improvement (CDI) is to link the physician's "clinical speak" with the diagnosis from a coding perspective. Clarification requests are most effective when the patient is still in house prior to discharge.

For several years, even before CMS implemented severity-based reimbursement, quality data reporting gained momentum among healthcare ratings agencies and vendors of health information management tools. Many realized the original diagnosis-related group (DRG) system, which was introduced in 1983, allowed considerable variation among patients-particularly Medicare patients-within each DRG. As a result, a range of severity-based methodologies and scoring systems developed.

By the time Medicare severity-adjusted DRGs (MS-DRGs) were implemented in October 2007, many hospitals had or were in the process of implementing CDI programs. With the transition to ICD-10 in 2013, clinical documentation will need to be even more specific. Hospitals should evaluate their systems' ability to support data integrity for the long term to accurately reflect patient acuity.

The checklist below can help hospital leaders evaluate their clinical documentation efforts.

Exhibit 1


When a CDI program focuses on accurately portraying patient acuity and risk of mortality, the hospital's case mix index more appropriately reflects the level of resources required for patient care. Such results can be sustained for the long term with appropriate monitoring and measurement of indicators. Just as important, however, is the significant improvement hospitals have seen in their observed versus expected mortality ratios compared with their peers and national and state averages. This improved profiling reflects the aspects of documentation that affect quality indicators.

Exhibit 2 compares a few hospitals that assessed their previous CDI program approach and then revised that approach to strengthen their focus on quality. As a result, each hospital improved physician involvement in the process.

Outcomes are influenced by many factors. Because many parties-including the hospital's compliance team and physicians-affect the continuum of care, hospitals need to ensure that they keep abreast of the many complex rules and regulations with which hospitals must comply. The CDI team and physicians should receive education to keep abreast of regulatory changes and evaluate their focus areas for improvement opportunities. The involvement of the hospital's compliance team involvement also is essential, given the continued emphasis on a compliant query process. Physician education and collaboration are necessary to define the medical staff's role in the CDI program and to achieve the increased data integrity required from clinical documentation specificity.

Physician Collaboration

The UCLA Health System in Los Angeles implemented a CDI program in September 2008. Tom Rosenthal, MD, chief medical officer for the health system, was instrumental in developing the initial message to the physicians regarding the importance of accurate, complete clinical documentation. He continues to be influential as a physician sponsor and respected leader in this initiative across the system.

"UCLA's physicians were not uninterested in the financial impact of accurate clinical documentation, but we surely got their attention around quality measures," Rosenthal says. "Each physician, as an individual or a group, has a reputation at stake in how his or her care is portrayed. Accurate mortality data are meaningful, and we would be foolhardy to ignore this part of the equation."

UCLA Health System kept the message focused with its physicians during the initial program rollout and education. Now going into the CDIP's third year, Rosenthal and other program leaders are focused on maintaining the momentum they have had to date with their efforts.

"To keep the program front and center, we are continually reminding our physicians of its purpose," he says. "As executive project sponsors, our CFO and I are equally interested in the quality and financial impact of accurate clinical documentation. There are many proposals for changing payment to reward quality, but the financial impact is not clear. The caveat is that there are dozens of quality measures at risk indirectly."

The experience at UCLA Health System emphasizes the importance of keeping the message focused on the purpose of the initiative while continually monitoring the physicians' response to requests for greater specificity and clarification.

Exhibit 2


Two Major Pitfalls

As clinical documentation grows in importance, some vendors are promoting their own CDI programs to hospitals. Hospitals should be aware of two approaches that are best avoided. First, hospitals should be wary of a CDI approach based primarily on revenue enhancement. It is easy to talk about quality, but hospitals need to evaluate quality metrics regularly to understand their impact before, during, and after the education and rollout of the program.

Second, if a software vendor or your clinical staff indicates that a high-cost software program has all the answers, be mindful that depending on tools to do all of the work of CDI can depersonalize the process such that the concurrent review team, physicians, and coding professionals refrain from applying critical thinking to cases on an ongoing basis. Although payment accuracy can be a benefit of a CDI program, accuracy and completeness of clinical documentation should be the objective. Software tools should be a component of the CDI program, but using a software-driven option could likely lead to higher margins only for the software company.

Keys to Success

Finance executives and other hospital leaders should be engaged at all levels of the CDI program using metrics that are consistent and widely applicable. To avoid implementing goals that are not related to management's goals or are not measurable, all levels of leadership should be represented during a meaningful goal-setting session, with checkpoints at each level during various stages of the goal setting.

The CDI team will need dedicated resources to follow through on identified opportunities. A commitment of resources is required to leverage any tools and manage the process changes. Usually, the CDI team is composed of dedicated nurse documentation specialists who work closely with the coders. As such, the team supports engagement of the resources for the long term with a commitment to the desired success. A measurable ROI ensures the allocation of resources on a consistent, ongoing basis.

A concurrent process measurement tool is also essential for evaluating the CDI program's progress and providing real-time feedback to program and physician leaders. Key considerations when evaluating the tools and software are to ensure there is balance between the ongoing development for each individual's core clinical skills and communication with nurses, physicians, and health information management (HIM) coders. All this must be accomplished while building efficiencies in the process with the support and direction from meaningful, user-friendly reports.

A software CDI tool should support an effective process rather than drive the process toward greater dependency. A desired outcome of such a tool is to enable each discipline to use its core competencies and develop them while teaming and tracking key data points for reporting. Reports should be real-time and provide clear and consistent metrics at the operational level that roll up into the broader metrics for the overall CDI program.

Providing real-time clinical documentation education to the team reinforces leadership's desire to instill a culture for change with clinical and financial integration. The education should be ongoing and foster less dependence on tools and systems for specific day-to-day skills and interactions. Organizations should ensure that the tools support the most efficient process, including process workflow tools, which sustain process improvements.

Technology should be leveraged to find any problems efficiently, while reports should be leveraged to closely monitor the operations for any potential breakdowns in the process. By accurately monitoring results on a timely basis, organizations can be regularly providing feedback to the staff performing the day-to-day tasks related to their CDI initiative.

Turnover among the CDI program team members (nurses and coders) and the medical staff, coupled with regulatory changes, necessitate realigning process management at times. Once the organization has put in place revised processes, improved employee morale will likely lead to better results over time. As the physicians, CDI program nurse documentation specialists, and HIM coding staff understand their impact on the CDI program's results, their role in the long-term success of the program can be even greater, and as a result, continued benefits can be realized.

Organizations can receive a variety of measurable benefits, but if the program's focus is on an established baseline with ongoing monitoring and measurement of tracking quality, clinical, and financial improvements toward key goals, organizations will be better prepared to make CDI improvements.

Hospital leaders are concerned with carefully managing government funding and other revenues. With an aging population and continued emphasis on Medicare and Medicaid budgets and the payer impact of reform initiatives, the need for this shift in CDI focus will only increase.

Shari Breuer is a principal, The Claro Group, LLC, Chicago, and a member of HFMA's Minnesota Chapter (

Venanzio Arquilla is managing director, The Claro Group, LLC, Chicago, and a member of HFMA's First Illinois Chapter ( 


Publication Date: Monday, August 01, 2011

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