Why documenting a myocardial infarction shouldn’t give physicians a heart attack

Clinical documentation improvement is about better patient care as well as financial sustainability. The key to successfully implementing a CDI program is showing physicians the value of clinical documentation and providing them with proper training and the right tools.

Despite the multi-faceted nature of healthcare, providing the best care for those who are sick and preventing illness in those who are well is a goal of everyone who works in the industry, from triage units to health IT developers and administrative teams.  While everyone plays a role in improved patient outcomes at some level, what has proven to be significantly challenging is that the rules of engagement are shifting, as most recently demonstrated by the vote to delay ICD-10.  While this certainly has stirred up a lot of frustration on the clinical end, it is having a profound impact on administrative side, as well.

Preserving financial integrity so that care teams can continue to provide quality care is top of mind for all healthcare administrations.  A recent study  conducted by the Healthcare Finance Management Association (HFMA) found that the greatest opportunity for financial improvement for hospitals is through better accuracy of clinical documentation.  It also identified the disruption of physician workflow as the most challenging barrier to improving clinical documentation.  The million dollar question is: how do we improve clinical documentation accuracy while streamlining physician workflow?

Not the CDI of yesteryear
Historically, CDI (clinical documentation improvement) has been viewed as a revenue cycle initiative tied to threats of fraud, error recovery and decreased reimbursement.  As a result, over the years, physicians have become cautious of these programs, viewing them as a series of administrative hurdles designed to optimize diagnosis-related group (DRG) payments, that do not directly impact patient care. In many facilities, physicians have avoided participating in such programs.  But that assessment of isn’t accurate.  CDI is about better patient care as well as financial sustainability.  The key to addressing the million dollar question, articulated above, is showing physicians the value of clinical documentation and providing them with the training and proper tools that enhance their ability to care for patients, not hinder it.

Providing focused ICD-10 physician education will not only reduce the burden placed on physicians, it will lead to more accurate clinical documentation.  The reality is that physicians already think about diagnoses in terms of the specificity required by ICD-10, it simply becomes an exercise in recording the details.  Consider a patient with an acute myocardial infarction.  Any physician assessing this patient would mentally run through the following details: initially diagnosing the infarction as a STEMI or NSTEMI, noting anatomic detail such as, left main coronary, left anterior descending, other coronary artery, left circumflex, and so on.  The key is to demonstrate that there are no new skills required, .physicians simply need to fully document their internal thought process – their full clinical diagnosis, using currently accepted medical terminology.

The ROI of CDI
With more than 2,800 physicians at five hospital campuses and a network of more than 100 primary-care and specialty clinics, Swedish Health Services is the largest nonprofit health provider in the greater Seattle area.  The organization first implemented their CDI program in 2011 in order to tackle the series of escalating regulatory and patient care reforms that were threatening their revenue streams and case mix index.  Post program roll-out, Swedish saw their mortality index decrease more than 1.29 percent.  Additionally, they have experienced a four percent shift in their case mix index (CMI) that has resulted in more than $10 million in ROI.

The ICD-10 delay is an opportunity for providers to evaluate the processes they currently have in place, and fortify procedures to ensure clinical documentation accuracy.  When implementing a CDI program, there are several strategies for success:

  1. Clinical focus: Integrating your CDI program with clinical quality initiatives, managed by clinical departments and overseen by a chief medical officer and supported by physician champions will create an environment of accountability and promote clinician engagement.
  2. Right tools at the right time:  Technology is only as good as staff education and proper implementation of the solution.  Carefully working with physicians and other members of the clinical team is necessary to assure integration of such solutions into efficient physician workflow.
  3. Identifying success metrics: Use your Case Mix Index (CMI) to demonstrate improved quality metrics as well as to monitor the impact the program has on compliance.  Organizations that have engaged physicians in their CDI program through such a clinical focus tend to see a CMI improvement between 4-8 percent.   The revenue cycle impact, while not the primary physician focus, is even greater than in non-clinically focused programs.

Although the delay in ICD-10 implementation was unexpected, health provider organizations have been given an opportunity for enhancing their CDI programs during the period of extension, allowing them to taking the time they need to turn a critical eye on clinical documentation accuracy, make sure they have the right education and tools for the job, the right people in place to support the initiatives, and the metrics in place to track successes and future opportunities.  The “final, final, final” ICD-10 transition deadline may still be unknown, but that doesn’t mean our preparation efforts should come to a grinding halt.


Tags: , ,

Dr. Paul Weygandt

About Dr. Paul Weygandt

This was a contributed post by Paul Weygandt. He has developed specialized approaches to physician documentation, assisting physician leaders in communicating the importance of accurate, legally-compliant clinical documentation. Paul attended the University of Cincinnati College of Medicine and the University of Missouri-Columbia School of Law. Paul has boy/girl twins – both of whom are physicians – and a daughter who is a business executive. He and his wife are excitedly engaged in the ongoing restoration of a 150-year-old farm. To see more content like this, visit the Healthcare section of the blog.