Transaction to Transformational: Using Technology to Promote Collaboration and Critical Thinking, Part II

Data for clinical and business intelligence can uncover significant opportunities within clinical documentation improvement.

In my previous article, I discussed the process of how transformational change occurs, through transparency resulting from strategic connectivity across the healthcare system. To expand on this theory, let’s examine the current state of clinical documentation improvement (CDI), and how implementing feedback and developing connectivity can directly affect operational improvement and quality of care.

Historically, CDI swiftly maneuvered floor by floor, reviewing medical records, generating appropriate queries, and trending found information for physician education. The onset of the electronic health record (EHR) presented ready access to each patient’s record, having a profound effect on the promptness of generating a query and receiving feedback from the physician. The downstream impact allows for a complete medical record at the time the patient is discharged, providing the coder thorough documentation for coding. Ultimately, the days in accounts receivable have decreased due to the implementation of CDI programs across the nation.

The tracking and trending occurred among physicians and CDI specialists. At times, a physician advisor may have been involved. Often, the administration would review a high-level cost-benefit analysis to support a CDI program and its overall impact on reimbursement. This practice seems prehistoric when one looks through the modern-day lens of healthcare.

As technology and healthcare regulations alter the healthcare environment, the functions of CDI will continue to evolve. There is a tremendous opportunity to expand the CDI specialist’s role, not only to improve physician documentation, but also to decrease (or, eventually, eliminate) inpatient and outpatient clinical denials – and, just as significant, to improve an organization’s overall quality ranking as it relates to patient safety indicators.

Business data intelligence is a proactive resource to support the expansion of CDI. For example, organizations are receiving an increasing number of inpatient and outpatient clinical denials, which often are sent to CDI specialists for a rebuttal or correction. Tracking and trending the data related to the inpatient claims denials, such as the diagnosis or procedure denied, physician, payor, etc. afford CDI the ability to educate physicians on the nuances of certain conditions. This intelligence can lead to open dialogue, with a focus on certain payors and diagnoses, and often, the result is a decrease in inpatient claims denials. This data is transferred from RCM to CDI on a transitional basis, and with the needed tracking and trending, this marks the beginning stages of transformation. Transformation requires continuous evaluating and monitoring as denials change, as do ICD-10-CM, PCS, and CPT code sets, not to mention provider guidelines and organizational staff members. Establishing a consistent feedback loop to the key departments, targeting issues to improve accountability while promoting improvements, prompts change.

Outpatient medical necessity requirements have a longstanding presence in this industry. As some services are starting to shift from inpatient to outpatient, CDI specialists are now commonly found in high-volume, high-dollar outpatient centers. CDI staff at such facilities have the opportunity to review the daily schedule for upcoming appointments, determine planned treatments, and find out if the treatment diagnosis supports the service scheduled. If not, the CDI specialist has the opportunity to speak with the physician before rendering the service.

Is the service medically necessary? If so, the documentation is evaluated in real-time, and physicians are educated on areas for improvement. For example, CDI has made a meaningful impact on infusion centers by improving documentation to support the reason for an infusion. The movement of CDI staff in high-volume/high-dollar clinics has secured notable financial improvement in certain outpatient arenas.

Aligning business and clinical intelligence allows continuous evaluation for areas of improvement and CDI expansion. This coordination is essential for healthcare organizations to achieve transformation in operational performance and quality improvements. Like most things in life, transformation takes time. Data, decision-makers, and a universal commitment to provide cohesive discussions and movement toward a common goal are vital; they will improve outcomes and ultimately, patient care.

Programming Note:

Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.