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In this Business Profile, Suzanne Whitworth, director at Deloitte & Touche LLP, and LaVerne Romberger, MSN, CCM, CCDS, clinical operations manager–Seton Healthcare, share leading practices for maximizing the potential of clinical documentation programs under value-based care.

How are payment trends influencing the role of clinical documentation?

Suzanne Whitworth, a director at Deloitte, discusses leading practices for maximizing the potential of clinical documentation programs under value-based careSuzanne Whitworth: As the market shifts from volume to value, it’s important to recognize that the information that feeds into safety and quality performance, as well as population management, is derived from clinical documentation and depends on its underlying accuracy and completeness. Third parties analyze claims data to determine how well an organization is performing. Failure to accurately capture severity of illness and risk of mortality, for example, can unfairly reflect on quality of care.

LaVerne Romberger Seton HealthcareLaVerne Romberger: Also important is to recognize significance in relation to the rise in consumerism. As patients seek to compare healthcare providers on quality, they are depending on third-party websites that grade physicians based on the performance data that are reported. Proper documentation allows the physician to accurately capture patient status throughout the period of care.

In addition, accurate documentation becomes increasingly important when managing population health. Collaboration across settings of care is impor-tant for illness prevention and management of chronic conditions. Documentation is the basis around which providers in inpatient and outpatient settings communicate their understanding of the patient’s condition. Without an accurate and complete patient record, the patient becomes more vulnerable to gaps in care that can contribute to readmissions and adverse outcomes.

Given that physician engagement is so critical to a clinical documentation improvement (CDI) program’s success, how can hospital leaders best garner this support?

Whitworth: Communication with physicians is essential. Organizations should have an infrastructure in place to routinely and consistently provide physicians with feedback about their documentation performance, particularly within the context of the effects on quality of care metrics and types of patients they are treating. Typically, programs will focus on areas such as severity of illness, case mix index, length of stay, and risk of mortality. For example, when a patient’s record lacks complete documentation to reflect the patient’s condition, the expected length of stay, true clinical condition of the patient, and severity of illness of the patient may be understated.

Also useful is providing scorecards. Hospital leaders can better engage physicians by sharing individual performance compared with organizational and national peers. 

In addition, direct interaction can be powerful and should not be lost with the transition to electronic health records. With the adoption of electronic health records, clinical documentation specialists have moved from being out in the nursing units and interacting with physicians at the time of care to working out of an office and relying heavily on electronic communications. Organizations need to still make sure their clinical documentation specialists are engaging face-to-face with key physicians and being visible. Such visibility within workflow helps medical staff appreciate and make most effective use of clinical documentation specialists as a resource in translating clinical terminology into the diagnostic terms that are needed for coding.

Romberger: Such opportunities for direct interaction work really well, because the best way to obtain physician buy-in to CDI initiatives is to speak their language and create an ongoing dialogue.

At first, some physician leaders may be hesitant to work side by side with a CDI specialist, because they may mistakenly believe the individual will be challenging their clinical perspective. As a CDIP [certified documentation improvement practitioner] myself, I always reassure them, “I’m a nurse just asking questions like I always would. Having this input is simply an opportunity to help you improve the accuracy and completeness of documentation so that the clinical data captured can accurately reflect the severity of your patient.” In fact, physicians often become very receptive to working alongside a documentation specialist as they naturally start to discover that more accurately reflecting severity of illness will align with recommended length of stay and improve their physician profiles.

Given your experience, what factors are most important for success of CDI programs?

Whitworth: Because physician engagement is so important, one key factor for success is often having physician advisors participate in the program. These advisors, or physician champions, can serve as the “voice of the physician” as well as function in the practical role of being a liaison between the CDI team and physician leadership. By bringing ideas from physicians to leadership, they can break down the perception that CDI is just about the hospital reimbursement.

Also important is ongoing collaboration between the coding and clinical documentation specialists. Both groups need to work together to have a robust DRG [diagnosis-related group] reconciliation process where the DRG that a clinical documentation specialist identifies ends up being different from what is final billed. You really need to take the time to review these mismatches together and go through the reconciliation process to understand the basis for the difference and future action plans to minimize the mismatches.

In addition, organizations need to build the infrastructure and governance to ensure sustained focus over time. Frequently, when CDI initiatives start up, a steering committee is put in place and there is a great deal of energy around activities. But over time, as programs mature, some of this energy can fade. To sustain success, you really need an ongoing forum where executive leaders, coders, clinical documentation specialists, and physician leaders can come together to share information and insights that will continue to move the program forward.

What are some key considerations for hospital leaders before implementing a CDI program?

Romberger: The CDI program should align with areas of focus that the hospital has greatest need to address. So it’s important to audit for areas of opportunity and prioritize educational efforts accordingly. For example, the organization may notice great frequency or significant revenue impact associated with inaccurate documentation of severity of illness. Having a shared sense of the top areas for focus will ensure documentation improvement programs yield the greatest benefit.

Whitworth: To kick off a successful program, there must be support from hospital executives and physician leaders. Topmost engagement is important because success of the program depends on efforts of many across the revenue cycle, quality, and clinical operations. Multiple stakeholders need to collaborate to ensure the alignment of the clinical documentation program, coding operations, and physician engagement.

A final consideration: Think broadly about which clinicians to include in initial efforts. Residents, interns, and mid-level practitioners all can benefit tremendously from CDI feedback and education because they also spend their time completing documentation within the medical record.

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Publication Date: Wednesday, July 01, 2015