When excellent doctors are poor documenters

Why it's important for physicians to communicate actions and reasoning accurately and quickly through clinical documentation

I sometimes like to think of Clinical Documentation Improvement (CDI) as investigative reporting for healthcare.  Similar to a crime scene that requires specialists with a keen eye to piece together information, in today’s healthcare environment, it takes expertise, tools, and training to accurately capture a patient’s story from ED admission all the way to discharge.  Additionally, as we continue to shift models of care, it’s becoming increasingly important for providers to track and care for patients not only while they are in the hospital, but also post-discharge. It’s not enough to provide great care, physicians need to be able to communicate clinical actions and reasoning accurately and quickly through the patient’s medical records; failure to do this successfully can trigger a tsunami-like blow to patient care, quality scores, and finances.

For the last several years, I have worked with physician leaders at large and small medical centers to identify and implement CDI opportunities that will enhance quality and better reflect the care clinicians provide.  I’ve learned how critical it is to engage physicians from the start and provide clarity among teams that this initiative is about quality, and not about codes or reimbursement. Physicians understand clinical reasons and the decisions that impact patient care, and embrace the idea that the better they communicate these in an electronic health record (EHR), the more a patient benefits.

Unfortunately, one thing I’ve learned is many physicians are not good documenters but are excellent providers.  A successful CDI program trains physicians to make sure the patient record is telling the true clinical patient story, including the care a physician provides and reasons for that care.  This is not easily done in today’s hectic and disparate healthcare environment where clinicians face many hurdles including EHRs usability, high patient volumes, and increasing federal regulations.

Why Raising the Bar in Clinical Documentation Works

Here are a few comments shared by clinical leaders:

  • Jennifer Woodworth, Director of Clinical Documentation Integrity at Swedish Medical Center:
    “Certainly there has been a financial impact [from improved clinical documentation].  Having a strong financial bottom line is critical for any program and over the last three years, we’ve brought in $18 million.  But more than half of the clarifications to physicians have been for severity of illness and risk of mortality. So, I think the impact is definitely better documentation, but an overall improved better quality of care at Swedish, as well. (Watch video)
  • Dr. Georges Feghali, Chief Medical Officer and Chief Quality Officer at TriHealth Medical:
    “Case Mix Index is something physicians don’t really understand.  The way you are documenting is proving the expected complications, mortality, and outcomes, and the CMI measures that.  The way it reflects on physicians is their quality scores – their observed versus expected complications and outcomes – and CMI measures that.  The only way to do this is use CDI and document properly because it levels the playing field.  It’s the old story, “my patients are sicker,” but nobody believes that, you need the numbers.”  (Watch video)

“From an organization standpoint, the biggest achievement is probably the move of our CMI and the quality awards we’ve received because of that.  When you have changed very little in your observed but your predicted has changed significantly, you realize you were doing the right things, you just were not getting credit for them.”

  • Dr Nick van Terheyden, CMIO, Nuance Communications:
    “Clinical documentation is the only arbitrator of quality of care measured by the government, insurance companies and all the quality metrics that are being reported, so if you are failing to capture the detail of the complexity of care you are providing in a note in appropriate form, you are being measured and judged as a poorly performing physician.” (Watch video)

To learn more about the impact clinical documentation improvement has on CMI, visit Nuance at ANI in booth #832, June 22 – 25 at the Venetian Palazzo Hotel, Las Vegas, NV, or schedule a clinical documentation assessment meeting.

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Mel Tully

About Mel Tully

Melinda (Mel) Tully is the vice president of clinical services and education for Nuance Healthcare, overseeing the development and expansion of clinical documentation programs and clinical education best practices. Mel joined Nuance in 1998 and has more than 25 years of experience in multiple healthcare arenas as a provider, clinical manager in a large academic facility, and as an expert in clinical documentation improvement (CDI). Mel attended Emory University, where she earned her Master’s degree in Nursing. She has been certified through the Association of Clinical Documentation Specialists (ACDIS) as a clinical documentation specialist, as well as by the American Health Information and Management Association (AHIMA) as a documentation improvement practitioner.