Outpatient CDI: A Clinical Perspective

EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part I was published on April 11, 2017 in the ICD10monitor eNews.

The first article of this series provided an overview, identifying and singling out key shortcomings and pitfalls of current programs. This article will focus upon outpatient CDI from a clinical perspective, describing and outlining crucial elements of a successful program that remain true to the description “clinical documentation improvement.” Physician engagement and participation in outpatient CDI initiatives require a unique approach to structure and process that incorporate solid strategic planning, development and execution.

Critical Elements: What are they?

There are a wide range of critical elements that must be considered in designing, planning, organizing and implementing an outpatient CDI program and, ultimately, driving short-term, mid-term and long-term successes. A major step in undertaking program development is to establish concrete goals and objectives for the program in terms of what the facility is attempting to accomplish in its outpatient CDI initiative. Reasonable program goals and objectives should embrace the commitment and dedication to affecting positive change in physician documentation to the extent it reflects and accurately reports the communication of patient care as well as the quality of care.

The National Academy of Science, formerly the Institute of Medicine, defines quality utilizing the following parameters:

• The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

• Quality care is safe, effective, patient-centered, timely, efficient, and equitable. Thus, safety is the foundation upon which all other aspects of quality care are built (https://archive.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/MitchellP_DPSQ.pdf).

As I pointed out in part I, and want to reiterate here, a byproduct of clear, concise and consistent documentation is establishment of medical necessity for all services ordered with associated hospital reimbursement, reduced financial exposure on the part of the patient, and enhanced patient care satisfaction. Established goals and objectives should incorporate the principle of the 6Rs:

• Right care
• Right time
• Right reason
• Right venue
• Right documentation
• Right clinical judgment and medical decision-making.

Fundamental to achievement of each component of the 6Rs is sound documentation—not more documentation or diagnoses per se—that effectively communicates the patient care provided. From a logical standpoint, physicians are not being asked to accomplish more than is expected from a patient-care perspective. Physicians owe it to their constituents to document effectively, and physician accountability is certainly a crucial part of program goals and objectives. Accountability is the key to achieving positive measurable outcomes in any CDI initiative. 

Documentation that Communicates: Another Critical Element

Documentation that communicates consists of numerous components, each interrelated and synergistic in nature. Every component serves to address the principle of the 6Rs, acting as necessary building blocks to attainment. Communication of patient care can be thought of simply as the exchange of clinically reasonable and necessary information among the patient, the provider and any other pertinent caregivers, and use of the information in the management of the patient. Exchange of information and use in the management of the patient governs and drives the practice of medicine.

The missing element rounding out the patient-care equation is the recording of this clinical information in a succinct and clear fashion. Improvement in the recording of this information requires a renewed emphasis upon the gather, process and transfer (GPT) mechanisms and mindset of physicians utilized in the practice of medicine. Capturing of the GPT mechanisms in documentation is a reasonable goal and objective of any CDI program.

Clinical Judgment and Medical Decision-Making

Generally speaking, patient care is predicated upon a physician’s clinical judgment and medical decision-making, which are based on employing years of medical training, ongoing training, honing of analytical and critical thinking skills, and drawing conclusions based upon available information.

Clinical judgment may be defined as the assessment of a patient’s clinical scenario and the initiation of action congruent with the assessment. Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option. It also refers to a cognitive process for selecting a course of action, in the context of health or medical diagnosis and treatment. Clinical judgment and medical decision-making are the “crux of medicine” with diagnosis, accurate and complete recording of the patient’s clinical information, and the facts of the case serving as the plot of the story or novel. Clinical judgment and medical decision-making represent a concluding chapter that doesn’t leave the reader hanging.

An unwavering focus upon diagnoses, similar in fashion to present-day inpatient CDI programs, in outpatient CDI, leaves the reader hanging without sound execution of a good story consisting of basic elements of character, plot, setting, dialogue and point of view, not forgetting clarity and distinctive voice.

Beyond Goals and Objectives: Documentation That Matters

Another critical element that is crucial to the ultimate effectiveness and success of any outpatient CDI program is engaging physicians as willing participants versus mechanisms of throughput that simply generate additional monies through hierarchical condition categories (HCCs) diagnoses capture.

What is the best way to achieve physician buy-in for any initiative designed to enhance complete and accurate documentation? Physicians truly care about the welfare of their patients from a clinical health perspective, whether it be managing an acute episode of sickness, managing an acute exacerbation of a chronic condition, or slowing the natural progression of chronic disease or disease prevention.

The Hippocratic Oath still has tremendous relevance to the physician-patient relationship including, in particular, the following: “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.” (Emphasis added to original from https://en.wikipedia.org/wiki/Hippocratic_Oath)

As pointed out in part I of this series, successfully engaging physicians in sound principles of CDI, and achieving measurable meaningful outcomes, requires incorporating and showcasing the patient as the main benefactor. Quality and completeness of documentation really do matter equally for the patient—from both a clinical and financial standpoint.

Documentation that communicates extends well beyond the physician order and includes physician office notes that contain pertinent and relevant clinical information and facts of the encounter. We have all heard about the exorbitant amount of time that physicians spend charting in the electronic health record (EHR) when compared to the amount of actual direct patient care. For every hour spent with patients, physicians spend two hours on EHRs and desk work, according to an Annals of Internal Medicine study (http://www.jwatch.org/fw111995/2016/09/06/half-physician-time-spent-ehrs-and-paperwork).

The very notion of documentation improvement sends shivers up physicians’ spines. To avoid this and similar viewpoints, strides must be taken to make a compelling argument and case for documentation effectiveness and its direct relationship and correlation with quality of patient care, degree of patient satisfaction and the physician’s business of medicine. Given physicians’ deep analytical skills and penchants for drawing their own conclusions from the available information and facts presented, the key is to provide the information in a reasonably succinct and logical fashion—no fluff, just the facts.

A strong convincing argument that can be made for clear, consistent and concise documentation centers upon the business and financial aspect of the practice of medicine, regardless of the physician’s level of interest.

The problematic sustainable growth rate (SGR) formula previously used to determine Medicare Part B physician reimbursement is now being slowly replaced by the Merit-Based Incentive Payment System (MIPS).NA

A stated goal and intention of this program, which includes development of alternate payment models, is to migrate away from fee-for-volume to fee-for-value; it encourages the practice of cost-effective, outcomes-based, and quality-focused medicine.

Clinical documentation effectiveness and quality serve as anchors for quality of medicine, employing a synergistic approach to medicine. The physician’s practice of medicine must embrace practical reflection and reporting of quality, cost effectiveness and achieved outcomes, all dependent in some form and fashion on the quality and accuracy in the communication of patient care. This highlights the importance of promoting the concept of the 6Rs as outlined above, which are all relevant to the practice of medicine.

A recent article in Health Affairs, entitled “The Medicare Access and CHIP Reauthorization Act: Effects on Medicare Payment Policy and Spending,” made the following point:

MACRA is a big, complicated undertaking that aims to substantially change the incentives providers face. These scenarios assume that MACRA is implemented as planned. Will MACRA fare better than the SGR in this regard? The new Medicare physician payment system can work if it meets two conditions. First, organized medicine, and individual physicians, must accept that one of their roles is to be responsible stewards of society’s resources and redesign their business model around value. Second, APMs must be well designed and implemented, which is no small feat. (Emphasis added- http://content.healthaffairs.org/content/36/4/697.abstract)

One Final Note

The overarching principle governing any outpatient CDI program is the provision of documentation that truly communicates the patient care provided and demonstrates medical efficiencies, quality, cost-effectiveness and outcomes. Focusing strictly upon reimbursement as a driving force for implementing an outpatient initiative will not materially provide any meaningful return on investment and at the very least will not engage physicians as participants in the program.

In part III of this series, I will outline the skill sets, core competencies and knowledge bases of CDI staff and other structural components necessary as a solid foundation in preparation for the rollout of an outpatient CDI program.