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A comprehensive look at how clinical documentation improvement and the actual practice of medicine overlap.

There are a multitude of business and ancillary healthcare processes that serve to support the practice of medicine.

That practice centers on direct patient care, facilitated and dependent upon specific synergistic processes that contribute to cost-effective, value-based, patient-focused services. Emphasis is placed upon “synergies,” recognizing that the sum of patient care is greater than the individual elements.

Let’s take a deep dive into the key comprised elements of patient care and outline how a truly effective, well-directed clinical documentation improvement program can achieve high performance in optimizing our worth and value-add to the practice of medicine.

The Practice of Medicine

The practice of medicine can be looked at and defined in many ways; just the same, standard to the practice of medicine is the physician’s utilization of clinical judgment, medical decision-making, thought processes, analytical and problem-solving skills, core knowledge, and dedication to maintenance of clinical acumen and up-to-date information. This allows physicians to provide the best possible care to their patients. Medicine encompasses a preventive component as well as the diagnosis, treatment, and management of diseases and other clinical conditions, whether acute, acute-on-chronic, or chronic.

Supporting the practice of medicine is what I refer to as the process integrity strategic control plan, and clinical documentation improvement specialists play an integral, vitally important role in this. In fact, clinical documentation improvement is so fundamental to the practice of medicine that I often refer to the role as being similar to the foundation of a house: without a strong, reinforced foundation, the integrity of the house ultimately suffers. The same holds true for the practice of medicine; without solid, complete, and accurate clinical documentation that adequately addresses, delivers, and provides for fully informed coordinated care, the practice of medicine and the patient ultimately suffer.

Strategically Integrated Process Integrity Control Plan

The practice of medicine in its present form requires a well-thought-out strategically integrated process control plan to maintain and support overall delivery of care. There are ancillary roles that contribute to the overall success of the healthcare delivery model. Some of these include patient scheduling and registration, insurance verification, clinical documentation, charge capture, coding, billing, and subsequent reimbursement and claim denial.

Fundamental to this is complete and accurate documentation that best communicates the patient care ordered and/or provided. Simply put, without it, all the ancillary work associated with the care, culminating in a claim and reimbursement, fails to materialize. Aside from the issue of reimbursement, the quality of continuity of care becomes a potential issue, including in post-acute care, referral for an outpatient consult, or transfer of care. Regardless of the setting, what is required is documentation that I have repeatedly said in the past reflects the following:

  • Right care
  • Right time
  • Right reason
  • Right venue
  • Right clinical judgment, medical decision-making, and thought processes
  • Right clinical documentation
  • Right spatial time, relevance, and situational awareness

Are We Actually Fitting In?

How do clinical documentation improvement specialists relevantly fit into the practice of medicine? To answer this, for one, we need to take a hard look at present-day clinical documentation processes and ask the question of whether our limited focus of chart review constitutes real clinical documentation improvement. I am going to take the liberty of responding with a resounding “no” to that question. The profession speaks of our role in improving the “telling of the story,” to the extent that all healthcare providers understand patients’ chief complaint, history of present illness, current care needs and treatment regimen, response to therapy, clinical stability, and anticipated discharge plans.

The fact of the matter is that our present chart review process merely focuses upon the capture and reporting of data used as throughput and input to outcomes such as avoidable complications, readmission rates being risk-adjusted, expected versus observed mortality, and Medicare spending per beneficiary. Accurate and complete reporting of diagnoses is critical to the achievement of effective publicly reported outcomes; I am certainly not downplaying the importance of securing all relevant diagnoses with appropriate clinical specificity. Pick up a chart of a patient recently discharged from a hospital and you will quickly recognize significant documentation gaps, including insufficient as well as just plain poor documentation. Yes, there will be diagnoses listed, including those specifically queried for, yet the clinical facts, information of the case, and context are often poorly defined through documentation. On the other hand, I am particularly at odds with the disregard and lack of any concerted effort toward actually improving the quality and completeness of the communication of patient care.

Given that most clinical documentation improvement specialists are nurses, and the nursing profession subscribes to the role of being a patient advocate and champion, it makes sense for CDI specialists to be advocates for documentation excellence beyond diagnosis capture.

Case in Point

Consider the following case study to demonstrate and drive home the point of the missing component of clinical documentation improvement initiatives among some providers. Say a patient was admitted through the emergency department from an inpatient rehabilitation facility, from which the individual was discharged to the acute-care setting after experiencing and being treated for an embolic stroke from poorly controlled atrial fibrillation. Three days into the inpatient rehab stay, the patient began to have recurrent intractable episodes of nausea, refused to eat due to worries about vomiting, and ceased participating in a daily prescribed regimen of therapies. The patient was subsequently transported to the emergency department for further workup and treatment, including possible inpatient admission. Anytime a nursing home patient is transported to the emergency department, there is a strong likelihood of admission, and such is the case here.

As part of my chart review for identification of clinical documentation improvement opportunities, the first customary step in the process is to take a close look at the clinical information, facts of the case, and context in an effort to develop an all-encompassing picture of the admission. I also want to determine the degree to which the documentation reflects an accurate clinical picture of what brought the patient to the hospital, exhibited and reported signs and symptoms, and the severity of illness. Additionally, I seek to learn whether there was any correlation of severity of illness with the intensity of service. To this end, I am forming an initial assessment of the principal diagnosis; that is, the chief reason that occasioned the admission. In doing so I have a better impression of the patient’s story that provides for the clinical context, setting the stage for the remaining part of the chart review process, including the possible necessity for a query clarification.

I skimmed through the ED record before advancing to the history and physical, specifically the chief complaint (CC) and history of present illness (HPI) for the patient. The CC and the HPI are at the crux of establishing medical necessity for hospitalization: a concept we are not directly tasked with fulfilling, but that which can certainly complement and support the utilization review/management and case management’s efforts.

The CC in this instance was “nausea, intractable” with an HPI that basically read like a history of past illness that outlined the key elements of the previous admission, with one or two sentences devoted to the present illness of nausea.

A brief word on chief complaint and HPI is in order. A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, say a patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC and be reported in the patient’s own words; as you can see above, “nausea, intractable” does not likely reflect the patient’s own words. The HPI represents the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements include the following:

  • Location (example: left leg)
  • Quality (example: aching, burning, radiating pain)
  • Severity (example: 10 on a scale of 1 to 10)
  • Duration (example: started three days ago)
  • Timing (example: constant or comes and goes)
  • Context (example: lifted large object at work)
  • Modifying factors (example: better when heat is applied)
  • Associated signs and symptoms (example: numbness in toes)

The critical importance of an accurate, clear, concise, and complete HPI cannot be overemphasized, mainly due to the role it plays in establishing medical necessity for the decision to hospitalize, as well as the need for the physician work and tests ordered downstream. Let’s revisit the case of the nauseous patient and construct a clear, concise, yet all-encompassing HPI:

  • Smith, a 75-year-old female patient well known to me, presented to the emergency department this morning at 7 a.m., transferred from the inpatient rehab facility next door with a chief complaint of nausea with intractable cyclical vomiting. She was recently discharged from the hospital with embolic stroke with significant sequelae of hemiparesis and dysphagia, and subsequently was treated at the rehab facility. According to the patient, she has been having worsening difficulty swallowing over the last two days, with increasing nausea and intractable vomiting to the point that she has been unable to eat. She reports keeping very little food down when she is able to eat and takes her regular meds. Of note is that the patient reports coughing episodes with shortness of breath, worse when she gets up in the morning and when she tries to eat. Chest X-ray in ED shows haziness in the right lower lobe with infiltrate, which could be an evolving pneumonia with concern for aspiration pneumonia – particularly troublesome in light of the patient’s current frail cachectic state. Hence, the necessity exists for admitting the patient and attempting to get ahead of the curve.

The clinical picture of the patient as evidenced in the above HPI properly depicts the physician work performed in uncovering, describing, and reporting the evolution of the patient’s present illness of nausea and vomiting. While medical necessity cannot be assured, this level of detail in the documentation certainly furthers an outside reviewer’s understanding and appreciation of the patient’s severity of illness and signs and symptoms.

What’s the Big Deal?

A quick review of this record revealed that the clinical documentation improvement specialist initiated an attending physician query seeking clarification of the cachexia from a malnutrition standpoint (i.e., what degree of malnutrition was there, given the patient’s reported BMI of 16.7?) While the query was certainly warranted in this instance, the question I would pose is this: should this be the only focus of the CDI specialist in the face of insufficient documentation in the HPI, with significant potential ramifications of a medical necessity denial? Being a realist, I recognize the fact that as a profession, we can synergistically work with case management and utilization review/management to enhance their ability to guide the physician’s determination of what the most clinically appropriate patient status is through effectively explicit documentation.

The assumption that querying physicians retrospectively for diagnoses that were evident (or at the least, plausible) at the time of admission represents documentation improvement is fundamentally flawed. Simply put, retrospective documentation improvement efforts, introducing diagnoses after the fact, is counterintuitive and counter-productive to the purpose of the medical record, as advocated in the American College of Physician’s Position Statement titled Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians, published January 2015 (ACP Position Statement):

  • The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
  • The clinical record should include the patient’s story in as much detail as is required to retell the story.
  • The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future.

Let’s Focus CDI Efforts Wisely

I am a true advocate for the patient and the physician, firmly believing that as a profession, we can be the driving force behind concerted efforts directed toward enhancing the effectiveness and completeness in the communication of patient care. Reconciling current CDI efforts at diagnosis capture, an indisputably important task in the revenue cycle, is vital to our creation of recognizable value and support of the practice of medicine.

I challenge everyone to begin the reconciliation process today.


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