A health system in New York developed a clinical documentation improvement program that resulted in substantial ongoing payment gains.
For decades, clinical documentation has been a necessary tool for ensuring maximum compliant payment from health plans and government payers. Today, however, clinical documentation is evolving into a crucial instrument for demonstrating quality, engaging physicians, and providing senior management with the information they need to lead their systems into the new era of value-based care.
To implement an effective clinical documentation improvement (CDI) program, healthcare organizations should take four steps:
- Hire and retain the best and brightest clinical documentation specialists.
- Establish metrics and measure outcomes to track the program’s effect organizationwide.
- Engage physicians and other providers to drive comprehensive documentation and coding that accurately reflects patient status, resources used, and quality of care.
- Equip senior leadership with the data and other tools they need to understand and promote the financial and quality improvements CDI can deliver.
The qualities of an effective CDI program are exemplified by a program launched by United Health Services (UHS), a 500-bed not-for-profit health system in New York. By taking the four steps mentioned above, UHS realized more than $500,000 per month in payment gains across its four hospitals and 25 primary care centers.
UHS began its CDI improvement efforts in 2001 by bringing in educators to work with physicians on improving documentation accuracy and then implementing a three-week pilot program for the orthopedic unit. In that program, coders and care managers worked together to identify comorbidities and other opportunities for coding improvements. After three weeks with two coders engaged in the process, the team saw revenue for the unit increase by $33,000.
UHS built upon this initial success by expanding the CDI program to more units and increasing coding staff. By 2005, as a result of more efficient and accurate documentation, the system had increased its revenue by more than $1 million annually.
After over 10 years of success, UHS sought to take its CDI program to the next level. Leadership suspected it wasn’t receiving maximum payment, and the health system experienced a lack of physician engagement and lackluster reporting capability. UHS set a goal of achieving $2.5 to $3.5 million in annual recurring benefit. In less than two years, the system achieved $6.3 million in validated annualized returns, a dramatic outcome that could only be realized by getting all stakeholders on board. Everyone—clinical documentation specialists, medical staff, and senior leadership— shared in both the transformation and the rewards.
Attract and Retain the Best and Brightest
A critical step in optimizing a CDI program is to standardize and clearly articulate the roles of the nurses and coders who translate physicians’ notes into data. To support progress in this area, hospital leadership must provide ongoing education and monitor individual and program results.
UHS’s original CDI team structure was coder-based. Working with the human resources department, UHS created a hybrid program of coders and registered nurse staff, bringing together complementary clinical and coding skill sets. Under the enhanced program, new CDI hires at UHS can be either degreed nurse RNs or related allied health professionals, or be professional coders with a degree in health information science or certified coding specialist or certified coding specialist-physician-based coding credentials. UHS also offers certification and education incentive programs to attract the best candidates and ensure a viable applicant pool in a challenging recruiting market for both coders and nurses.
To ensure that everyone would pursue the same program objectives and goals, UHS’s clinical documentation specialists participated in classroom education followed by intensive mentoring where senior-level specialists were assigned to one or two less-experienced colleagues to review records and discuss and apply what they had learned in the classroom.
Through effective mentoring, UHS recognized and supported the qualitative skills that are fundamental to the clinical documentation specialist job:
- Face-to-face interactions with physicians to foster solid relationships, trust in clinical skills, and information sharing
- Accurate and timely chart review that includes the identification of missing or vague physician documentation
- Concise query writing that physicians can easily understand and support
- Timely reconciliation of all cases to include accurate assignment of DRG or severity of illness (SOI)/risk of mortality (ROM), based on physician query
Clinical documentation specialists also participated in physician education at UHS. As specialists, coders, and physicians learned more about each other’s roles, UHS began a culture shift that was critical to the initiative’s success. The clinical documentation specialists remain involved in data management and reporting, giving them more ownership of their work, while also contributing to improved data quality.
Establish Metrics to Measure and Support Continual Improvement
As the push toward value-based care continues, CDI will be instrumental in the accurate reflection of the SOI/ROM for both physician and hospital scorecards. Hospitals and health systems that wish to build dynamic CDI programs must identify and track key metrics for all stakeholders, including the following:
- Coverage rate, or percentage of charts reviewed (best practice: greater than 90 percent)
- Physician query rate, or percentage of records that elicit a query from the physicians (best practice: greater than 30 percent)
- Query response rate (best practice: greater than 90 percent physician response rate)
- Query agreement rate (best practice: greater than 90 percent physician agreement rate)
- Case mix index change
- Financial benefit of achieving best practice coverage rate (more review, resulting in more queries, better information, and more comprehensive documentation)
- SOI/ROM improvement (i.e., risk adjustment impact for CDI program)
Through collection and analysis of these metrics, leadership can identify unfavorable trends and create solutions. For example, if clinical documentation specialists are asking the same question again and again to clarify documentation, it may indicate confusion among physicians (or poorly worded queries). A low response rate could indicate that the physician or physician group is not fully engaged in the CDI process, or that there is a lack of understanding of physicians’ responsibilities relative to CDI.
Query agreement rates can help pinpoint where coding does not recognize new clinical terminology or when a physician or physicians might require an update on the latest acceptable terminology. Small variations can lead to lost compliant payment. For example, physicians once could document a fracture of any bone without additional specificity. Now, under ICD-10, physicians must further indicate what part of the bone was broken, on which side of the body the fracture is located, whether the fracture is open or closed, and the severity of the fracture. Without all the details, the appropriate codes can’t be applied, resulting in additional provider queries, delayed billing, and denials.
Ongoing feedback bolsters clinical documentation specialist training. It is essential to understand diagnoses not supported by clinical indicators. Early identification of query opportunities and ongoing education allow CDI team members to grow and optimize performance.
Under UHS’s reinvigorated CDI program, data measured for each clinical documentation specialist include the coverage rate for assigned patient populations, the number of physician queries generated, the number of responses received from physicians treating their patients, and the rate at which physicians agree with the query placed. Data from these productivity metrics help CDI leadership pinpoint and provide training to staff members who need it. This proactive approach results in a higher physician agreement rate and accurate documentation in the medical record, including a clear description of patient acuity, SOI, and ROM. Accounting for these last three factors is a common risk-adjustment methodology for comparing physicians and health system quality—and critical to payment in New York.
In six months, UHS’s medical/surgical SOI increased from 2.07 to 2.21, and the ROM moved from 1.78 to 1.94. From July 2014 to February 2016, the number of monthly queries bounced from 161 to 306, and the query rate increased from 10 percent to 15 percent. Simultaneously, the “no response” rate plummeted from 46 percent to 10 percent, with 16 consecutive months at 10 percent or below.
For long-term success, hospital leaders should develop an immediate action plan to correct any negative trends and to continually recognize and report successes among both CDI team members and physicians. For example, UHS uses the physician response and query agreement rates to identify providers who are not participating fully with the CDI program. Addressing concerns with the providers helps them understand the absolute necessity for a CDI program, and improves both physician response and physician agreement rates.
As the physicians’ knowledge of CDI deepens and participation in the program increases, documentation in the medical record improves, allowing accurate coding and assignment to the appropriate DRG.
A strong CDI program requires a challenging move away from “business as usual,” and such a move requires a team drawn from all corners of the hospital. To ensure physicians were part of the required cultural shift, UHS identified a physician champion, assembled a team of key physician leaders, established an escalation process for unanswered queries, enhanced query processes, educated CDI staff and physicians on the changes, and established dashboards that allowed physicians to see their personal and team results and created healthy competition among the physicians.
UHS senior executives began by establishing an implementation structure overseen by a clinical documentation steering committee made up of executive sponsors and UHS team leaders.
Under this umbrella, UHS solicited participation and support from a physician CDI champion team, the chief medical officer, and department chairs. The CDI team worked with physicians and physician extenders.
Physician champions were integral to UHS’s CDI efforts, ensuring consistent communication among providers, clinical documentation specialists, and administrative leaders. Physician champions helped break down barriers between the CDI team and medical staff in an effort to bring on board physicians who didn’t understand or weren’t engaged in CDI. The physician champions also were instrumental in sharing data regarding a physician’s performance, including metrics such as query response rate, query agreement rate, and case mix index change.
The CDI steering committee and the medical executive committee established a clear physician query escalation process to help ensure each medical record was a complete and accurate accounting of the patient’s experience in the hospital. Under this model, physicians are required to respond to each query. If a physician does not respond to a query within 24 hours, an email is sent to the physician and the physician champion. After three to four days, the director is contacted, and after six days, the chief medical officer is notified of the issue.
New query process flow maps provide consistency, helping both the clinical documentation specialists and physicians better understand what to expect. Standardizing query placement, follow-through, and resolution has greatly reduced consternation over what is proper procedure. Also, the presence of clinical documentation specialists on the nursing units facilitates communication with physicians.
When it comes to engaging physicians, data are most valuable. A physician CDI dashboard helps UHS communicate physician expectations and measure performance. Each physician can see his or her personal scorecard on dollars lost, financial benefit, ignored queries, case mix index, SOI/ROM, query agreement rates, and more. This transparency facilitates positive competition among UHS physicians and provides an incentive to improve.
Physician engagement is predicated upon effective education and communication. To avoid or reduce repetition of queries, UHS provides education for physicians in person, via the UHS website, through newsletters, and using the online CDI training tool. While the clinical documentation specialists work to become more sophisticated in their queries, the hospital can increase comprehensive documentation and ensure compliant payment if the physicians are also improving the information they provide.
To that end, UHS created disease-specific prompts for physicians in the electronic health record (EHR), which include the type of documentation required and clinical indicators to address. For example, one of the most common reasons patients are admitted at UHS is to treat congestive heart failure. The CDI team worked with the IT department to build prompts in the EHR to remind physicians to specify details of each patient’s heart failure, including acuity and whether the heart failure is systolic or diastolic.
UHS’s efforts paid off. From July 2014 to January 2015, while the coverage rate went from 46 percent to 68 percent, the query response rate jumped from 71 percent to 95 percent, and the query agreement rate increased from 77 percent to 86 percent.
Equip Senior Leadership
To ensure continued buy-in for the CDI program among staff, senior leaders must be equipped with the latest data and a keen understanding of the CDI program’s impact on both finances and key quality indicators. Senior executives also must appreciate the critical importance of quality metrics as payment shifts toward pay for performance and communicate findings to key stakeholders.
UHS leadership recognizes the importance of a top-down commitment to the success of the CDI program, metrics to demonstrate continued performance, and communication of data to key stakeholders. UHS effectively uses this approach to support performance and sustain program success.
UHS restructured its CDI program to report to the CFO, emphasizing the link between maximum compliant payment and CDI. The hospital also added a monthly leadership meeting, including staff from health information management, finance, and physician leaders. At these CDI-focused meetings, UHS reviews best-practice metrics regularly to remind all involved of ongoing goals.
In addition to individual physician dashboards, UHS leaders use a departmental dashboard, which clearly shows financial benefits trending up as the coverage rate, physician response rate, SOI, and ROM all increase.
From July 2014 to January 2015, the CDI program’s financial benefit skyrocketed from $68,372 to $524,317, eclipsing the original goal established by UHS. Simultaneously, the Medicare medical/surgical case mix index improved,from 1.61 to 1.80.
UHS also has capitalized on its CDI program to launch a bundled payment initiative. The CDI program was essential in early and accurate identification of patients qualifying for the bundles 85 percent of the time. Having the correct DRG capture process already in place made it possible for UHS to launch the bundled payment program in less than three months, enabling early intervention and care redesign for UHS’s bundled care patients.
Data not only help UHS’s leadership understand the capacity for CDI to drive financials, but also give them powerful talking points to help bring physicians on board and reward clinical documentation specialists. UHS’s experience demonstrates how by understanding the positive impact of a highly functioning CDI program, a hospital’s or health system’s senior executives can help position the organization for success as health plans shift to reward hospitals for demonstrated outcomes.
Many hospital leaders are reluctant to tackle CDI because they simply do not understand how to do so. But once they take on this challenge, nearly all will find that straightforward improvements can yield rich opportunities. By training staff, engaging providers, and arming leadership with compelling metrics, hospitals and health systems stand to enhance their bottom lines. Moreover, as health care shifts from fee-for-service to fee for value, these leaders will find that a strong CDI program also promotes teamwork, improves communication, and highlights further opportunities for advancements in quality.
Laura Jacquin, RN, MBA, is a partner at Prism Healthcare Partners, LTD, Indianapolis.
Tricia Jewson, MHA, RHIA, CHDA is Senior Director of HIM and Coding at United Health Services, Johnson City, NY.
Michele Palmer, RHIT, is Director of Facility Coding and Clinical Documentation Improvement at United Health Services, Johnson City, NY.