In January, For The Record published an article on the difficulties and benefits of implementing a clinical documentation improvement (CDI) program. As well as input from me, it includes valuable insights from Drs. William Walker and Jerri Williamson. Including physician input to the article underscores one of the main success factors of any CDI program. That is, the need for physician involvement.
When we say physician involvement we really mean involvement! Peer to peer communication is widely viewed as the best practice in any physician interaction.
Physician champions are essential for training and explaining. They are needed to not just explain the “what” of CDI but also the “why”. Giving good reasons to alter documentation behavior, backed by actual case examples and financial impacts, greatly increases your medical staff’s motivation to change.
Another key point mentioned in the article is healthcare’s natural tendency to link CDI with coding and reimbursement. Instead, I propose that HIM professionals and physician advisors are better served to focus on quality data, accuracy of severity and acuity.
Much of a hospital’s coded information gets translated into publicly available physician ratings and rankings. And since physicians are extremely competitive, they will work hard to protect their image and make sure they are not an outlier of adverse outcomes. Accurate documentation portrays the correct severity of illness of a presenting patient and therefore communicates the correct outcome.
Finally, better documentation improves patient outcomes. All healthcare professionals who subsequently treat the patient see a complete picture of condition and treatment.
In summary, the goal for HIM and CDI professionals is to train and educate physicians about coding and reimbursement implications while also stressing the end product: improved patient care and better quality indicators. Your commitment to these goals, clearly communicated, results in stronger physician commitment and better clinical documentation.