In this business profile, Tim Marshall, managing director at The Claro Group, discusses the value of rethinking and retooling clinical documentation improvement.

Tim MarshallHow has clinical documentation improvement (CDI) changed over the past five years?

The implications and benefits of CDI have continued to evolve in recent years. The Affordable Care Act—and the corresponding movement towards pay-for-performance and value-based care—has magnified the importance of accurately reflecting the acuity of a hospital’s patient population. Plus, many hospitals and health systems are beginning to apply CDI to more patient settings and patient populations—well beyond the traditional adult acute inpatient population. Hospitals and health systems can benefit by applying CDI concepts to hospital-based outpatient encounters, professional claims—if the hospital employs any physicians—pediatric and neonatal  populations, and inpatient rehabilitation encounters, among others.

Why is CDI more mission critical now than ever before?

Healthcare providers as a whole are experiencing increasing financial pressure. Many hospitals need to either find more revenue or cut staff. Everyone is obviously more comfortable with finding more revenue, but they frequently don’t realize the extent of the remaining opportunity for improvement.

Payers are also more focused on connecting payment to the quality of care being provided. The shift toward value-based compensation requires organizations to simultaneously navigate two different reimbursement models that have different features and elements that influence the provider’s reimbursement. CDI programs that are narrowly focused are not able to perform as well—under either payment model—as our clients’ programs that are approaching CDI comprehensively. A highly-functioning CDI program can help a hospital prosper under both volume-based and value-based reimbursement; however, many organizations have designed their CDI programs for only one reimbursement model, and in some cases, even only one payer. We see a number of hospitals overlooking many of these opportunities, including dollars related to quality incentives and penalties. Some of our most sophisticated clients are using CDI to differentiate their hospital or hospitals from others in a crowded provider market.

Most hospitals and health systems have a CDI department. How can organizations determine whether their CDI programs are achieving what they can or should?

One of the most common things we encounter is hospitals assuming they’ve done all they can with CDI because they have several people on their CDI team, and the team may have an expensive workflow tool. They may even report how they have achieved a particular financial result. We urge hospital executives to challenge the assumption that the CDI team has maximized their performance. Just like any other department within a hospital, there are a lot of different elements that distinguish the successful CDI program from the less successful. We have seen CDI programs have challenges with a multitude of issues that can broadly be placed into three categories: people, processes, and technology.

With respect to people, it’s not just a matter of having staff in place. Organizations need to have the right people, with the right training and coaching on an on-going basis, with the right structure, and with the right direction. These resources must have strong relationships with the medical staff throughout all hospital departments. They also have to consistently follow a well-considered process, designed to reflect the program’s goals and objectives. Such a process must define what types of cases need to be reviewed and how frequently, as well as how to assign cases, query physicians, follow-up on unanswered queries, work together with the coding function, and many other factors.

In terms of technology, we often see hospitals put computer-assisted coding solutions in place and assume this will take care of any CDI team needs. However, technology is merely one tool in the CDI toolbox, and all solutions have advantages and disadvantages. An organization cannot fully maximize its program without considering the people and processes surrounding the technology.

CDI has not always been relevant to every hospital, but that is changing. Could you talk about the effect of this?

The reimbursement for pediatric hospitals has changed a fair amount in the last few years. Pediatric inpatient encounters increasingly are migrating toward some form of DRG-based compensation. Although accurately reflecting the acuity of the pediatric population has always been important, it now has more of a direct financial impact. That has opened up a need for CDI in the pediatric and NICU space. We also see an increasing demand for CDI among inpatient rehabilitation and other patient groups.

Overall, in addition to expanding programs in these specialty hospitals or units, clients are aiming to build out their work in regular hospitals as well, ramping up their efforts on claims for outpatient encounters, including observation, emergency department, cath labs, GI labs, and other ancillary settings.

What are some key considerations organizations should keep in mind when choosing an advisor to help with CDI?

Hospitals should seek a partner that can support the full depth and breadth of what a CDI program requires. This advisor should be agnostic on the various CDI software tools and appreciate the advantages and disadvantages of each. This way the consultant can help organization leaders work through and optimize different options. Hospitals also want to find a group that brings a complete stable of resources to the project, including clinicians, coders,  technologists, financial analysts, and consultants who have coached hospitals in the change management process. Technology companies are good with technology but not necessarily good at consulting, guiding, and coaching clients through these types of complicated issues. Also, having a depth of experience is key. A good advisor should have been highly focused in the CDI field for at least 15-20 years.

How does your organization help clients start to revamp their CDI programs?

We typically begin with a comprehensive evaluation to gain a complete understanding of the client’s existing operations, as well as understanding what is needed going forward. We structure these assessments or evaluations based on the three categories I mentioned before: people, processes and technology. During the evaluation, we also review medical records to gauge the scope and scale of the opportunity. We then look at the underlying causes of any gaps to help us determine what needs to be done to realize improvement. Once we complete the assessment, we can then design an implementation plan that is appropriate for the client in the specific settings and for the particular care on which the client wants to focus.

As healthcare organizations partner with you, what advice would you offer so they can best set themselves up for success?

I think hospitals frequently approach CDI with an assumption that their entire success revolves around physicians. Although we recognize the importance of physicians in the process, we typically find that the greatest opportunities are not related to the physicians. For example, CDI staff may not be querying physicians in the appropriate way or in a way that physicians fully understand what is expected of them. In that case, reworking the communications approach, the organization can see great benefit.

To ultimately be successful, organizations need to be open to viewing CDI in a different way. They must embrace the idea of change and be willing to approach the process as a constant evolution in which the organization partners with an external expert to identify improvement opportunities and work to resolve them.

Are there any educational materials you would like to share to help healthcare providers with their CDI efforts?

Learn more about strategies for reimagining a CDI program.

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The Claro GroupContent for this Business Profile is supplied by The Claor Group. This published piece is provided for advertisement purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions of those profiled are those of the individual and not those of HFMA. References to commercial manufacturers, vendors, products, or services that appear do not constitute endorsement by HFMA.

Publication Date: Saturday, October 01, 2016