Nuance Communications
Clinical documentation improvement (CDI) is central to the success of accountable care organizations (ACOs) and other value-based healthcare models. Completely and accurately capturing and documenting the severity of patient illness, including all comorbid conditions, is essential not just for proper reimbursement, but also for accurately assessing patient populations, the services they use, and their risk. This has broad implications for ACOs and shared-risk models.
Financially, the impact is clear. If the patient’s condition is not documented properly – such as failing to describe a comorbidity using the correct language – this can result in miscoding, reducing the potential reimbursement. Moreover, any hospital, health system, or ACO that fails to properly capture the severity of illness across its population will not compare favorably to its peers that do a better job of clinical documentation. In the value-based world, this can impact everything from bundled payments and payer negotiations to public quality ratings and reputation in the community. Simply put, no one wants to recommend or visit a physician or a hospital that looks like they are falling behind on quality when they offer the same service at the same or higher cost.
Quality-of-care implications
Sub-optimal clinical documentation can also impact patient outcomes and quality-of-care delivery. Ensuring the entire care team has access to the right information at the right time regarding a patient’s condition improves care coordination and helps clinicians form a clinical impression more quickly and accurately. This is particularly important given the flood of data that clinicians must navigate today. What used to be summarized in a one-page note now spans 10 pages thanks to digitized records. EHRs provide huge amounts of data, but not necessarily in a cohesive way. Incomplete or inaccurate documentation compounds this challenge.
The recent transition to ICD-10 gave added impetus for all healthcare organizations, including ACOs, to establish CDI programs. It is estimated that 80 to 85 percent of healthcare organizations have some program for improving clinical documentation.1 But how effective are these programs? Are they addressing the underlying causes of documentation failures or simply creating a false sense of security?
5 key success factors
Through my work with healthcare organizations of all sizes, including ACOs, I believe there are five key success factors for an effective CDI program.
1. Clinical focus
A successful CDI program must be clinically based and focused on the key points where clinical and coded information intersect. Clinicians think and communicate in clinical terms – diagnostics, diagnoses, and treatment plans – rather than in ICD-10 coding terms. Effectively translating the clinical world to the coded world is the goal of CDI. That means validating questions about the patient record in clinical terms, because that’s what clinicians understand.
Given the complexity of the codes (there are approximately 68,000 ICD-10 diagnosis codes, with more on the way), it is unrealistic to expect physicians to navigate that complexity. An effective CDI team must have the resources built in a way that helps them assess the patient record clinically and appropriately. This can mean having defined documentation strategies and algorithms to help clinical documentation specialists (CDS) and nurses evaluate the clinical portion of the record and understand how it drives to the coded record.
It also means having experienced nurses (or international physicians in residency) with strong critical thinking skills in this role who have the clinical understanding to talk with the physicians in clinical terms. Having professionals who understand the record clinically – and can translate it properly to the financial terms a coder would use – is crucial to the success of the CDI program.
2. Measurement and benchmarking
Most CDI programs have some form of measurement, such as measuring physician responses to queries. This is important, but even more important are measures that compare your organization’s performance against that of its peers. Benchmarking your CDI performance against others is the only way to identify where your organization is lagging behind. Moreover, measurement is not a one-time event but should be an ongoing performance improvement activity.
This may require enlisting external expertise to help establish the infrastructure for ongoing measurement and benchmarking, focused on identifying areas of opportunity for performance improvement.
3. Ongoing education
Many healthcare organizations ramped up their clinical documentation programs during the ICD-10 transition, only to let them lapse once the deadline passed. But clinical documentation is continuing to evolve – a second wave of more than 55,000 new or modified ICD-10 codes is slated to come into force later this year. Establishing ongoing education is essential to keep pace with what is sure to be a state of continual evolution ushering in even greater complexity in the future.
To be effective, CDI education must be informed by the latest information and best practices, leveraging the experiences of other organizations that are outperforming their peers.
4. Expert support
Sometimes being so close to one’s own processes blinds us to areas that need fixing. Having the support of a trusted expert brings a fresh perspective and insights gained from other organizations facing the same challenges. Working with a partner who can provide an objective, comprehensive assessment of your organization’s CDI program and processes helps identify and prioritize overlooked opportunities for improvement, not only for ICD-10 but also for quality of care and other priorities. It also places those activities in the context of the broader marketplace, helping improve your performance within your peer group.
5. Make the right technology investments
The right technology can make a tremendous difference in helping achieve your organization’s CDI goals. Leveraging technology to draw the most clinically relevant information from the patient record – both structured and unstructured information – not only improves the quality and accuracy of clinical documentation and coding, but also the quality of care. The key is investing in technology that makes your CDI program more efficient, while also providing the flexibility to evolve as needs change – which they certainly will.
Investing in technologies that improve clinical documentation efficiency by eliminating manual and redundant tasks enables organizations to meet evolving needs without adding headcount. It also improves the quality and accuracy of information, essential prerequisites for advanced applications of data, such as predictive analytics for population health management.
Start with an independent validation
Already doing these five things? Congratulations, you’re a step ahead of most ACOs. But no matter where your organization is on the CDI journey, you may benefit from an independent assessment. Having an experienced clinical documentation partner assess your program will validate your progress to date and give you a baseline for future improvements.
True organizational change takes time. The sooner ACOs start identifying CDI opportunities and benchmarking against their peers, the better positioned they will be to meet the challenges of the value-based world.
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