Clinical documentation is the foundation of a patient’s medical record and captures patient care from admission to discharge. Studies show that clinical documentation could be improved, on average, in more than 50% of medical charts. This is problematic because complete, accurate documentation can prevent ambiguity of diagnoses and treatment, while inadequate documentation can lead to higher readmission rates, longer lengths of stay (LOS), failure in appropriate post-discharge follow-up, increased costs and medication errors.

The medical record also drives the assignment of International Classification of Diseases (ICD) codes, which are used for performance tracking (e.g., admission and infection rates) and understanding burden of disease.

Accurate, thorough clinical documentation benefits patients, healthcare providers and healthcare facilities. Niagara Health Systems implemented a clinical documentation improvement (CDI) program, including an enhanced physician query process, to improve the accuracy and completeness of their medical records, and found healthcare and organizational benefits. 

The importance of clinical documentation

Clinical documentation is the foundation of a patient’s medical record. It captures patient care from admission to discharge, including diagnoses, treatment and resources used during their care. When the documentation is complete, detailed, and accurate, it prevents ambiguity, and improves communication between healthcare providers. Conversely, incomplete or inaccurate documentation can adversely affect the quality of patients’ care, leading to medication errors, longer lengths of stay (LOS), inappropriate (or no) post-discharge patient follow-up, higher readmission rates and increased care costs.

Recent chart audits/studies done by 3M Canada Health Information Systems staff, in Ontario, show that more than 50% of medical records, in most hospitals, could be improved with more complete and accurate documentation. These gaps are important opportunities for physicians and/or health records coders to improve data capture and documentation, leading to improved quality metrics and data.

The challenge of translating clinical documentation into coded data

Once a patient is discharged, that patient’s medical record is sent to the health records department to be processed and coded. The coder reviews the available documentation, and translates diagnoses, procedures and treatment into the appropriate International Classification of Diseases (ICD) codes to create a record of the patient’s medical journey.

This coded and abstracted data (submitted to the Canadian Institute for Health Information CIHI) is the foundation for managing and delivering appropriate healthcare services. The data is used for patient quality and outcome metrics – for example, determining a patient’s expected length of stay, the hospital’s mortality rate, hospital infection rates and complications. Many of these indicators are publicly reported or benchmarked against other peer hospitals for comparison. Within healthcare facilities, the data is used in patient evaluation and treatment, and for strategic planning. At regional, provincial and national levels, it is required for planning, research, education, policy development and implementation, and funding. It is imperative that the information is of the highest quality.

However, converting medical documentation and clinical terminology into the correct codes from a long list of options can be challenging. And it is even more difficult when the medical documentation is not clear, specific or accurate, often due to missing or incomplete information.

What is Clinical Documentation Improvement?

Clinical Documentation Improvement (CDI) is a process to facilitate an accurate representation of healthcare provided through complete and precise reporting of diagnoses, comorbidities and procedures to ensure the acuity and complexity of the patient is available to be coded and is a growing need for all Canadian hospitals

Successful CDI programs include a CDI specialist – an experienced health information management professional or highly skilled nurse who reviews charts for clinical documentation completeness – to ensure the documentation fully reflects the patient’s episode of care. The CDI process enhances patient outcomes and in turn enables complete and accurate coding, and allocating appropriate Case Mix Group (CMG) assignment.

While CDI programs are typically used in acute care hospital settings, their philosophy, principles and practices can be applied to any healthcare sector where a clinician provider is documenting a healthcare encounter in a patient record. The outcome and impacts of clinical documentation are increasingly impacting funding decisions in all healthcare sectors; the goals of a CDI program to promote better patient care and outcomes, and enhance clinical service planning and delivery, apply equally across the healthcare continuum.

CDI programs have been used in the US for more than 20 years. With changes in funding methodology and the need for high-quality documentation, CDI is becoming increasingly common in Canada.

How to create a CDI program

The first component of a CDI program is a chart review from a clinical and coding perspective to assess gaps in documentation and their effects on coding – including resource intensity weight (RIW), coding deficiencies, harm metrics, length of stay (LOS) discrepancies – and identifying the areas that require attention and improvement to meet the organization’s goals.

The second component consists of customized education for physicians, CDI specialists and/or health information management (HIM) professionals to make every medical record more accurate and valuable. This step also includes implementing queries (requesting clarification or specificity from the physician regarding a condition) and monitoring the query process.

The final component is a review of the program once CDI changes have been implemented, to evaluate the success of the program, and then monitoring changes/impact based on ongoing data analyses.

The CDI program, or parts of, has been implemented in several hospitals in Ontario so far. One such hospital was Niagara Health Systems (NHS). Within weeks of their chart review, NHS made changes and saw great improvements.

Niagara Health Systems CDI Journey

Niagara Health Systems started their CDI program with an external chart review of 300 patient records to see if there were opportunities to improve documentation and coding. The clinical and coding expert reviewers identified incomplete, missing and conflicting documentation that affected the CMG and weighted cases. Their data analysis included an extrapolation of the resource intensity weights and cost per weighted case (CPWC) impact (showing the potential financial impact) and evidence of other metrics/data affected.

Based on the results of the document audit, NHS implemented a CDI program. To improve the accuracy and completeness of their records, they enhanced their physician query process, so that their records captured a true picture of the patient’s acuity.

One of the first set of queries involved any charts from April to December 2016 with unspecified pneumonia as the most responsible diagnosis (MRDx). The process involved a standardized query for pneumonia, with an area for the CDI specialist to record supporting clinical indicators and a place to clarify the type of pneumonia specified. This printed query form was placed in the physical patient record and kept in the incomplete chart area for the physician to review. After the physician completed the form, specifying the type of pneumonia required for coding, the form was added to the chart as a part of the legal medical record.

The impact was significant: the improvement in documentation specificity increased the RIW and expected length of stay (ELOS) in 76 cases of pneumonia.

The overall impact on weight and length of stay for 76 cases of unspecified pneumonia was adjusted. The results are as follows:

A negligible number of pneumonia queries have been required since that time. Currently, physicians document as per standards learned through the query process. Coding queries are a part of Niagara’s deficiency policy and a lack of response to a query is treated the same as within their chart completion suspension policy.

Recognizing the value of comprehensive medical records, NHS held in-person training sessions and developed a physician education video for new onboarding physicians as well as education for the current physician population. The process has brought awareness of the importance of clinical documentation improvement, physician involvement/education and the next steps at Niagara Health Systems as they journey along the continuum of success.

Clinical documentation is key in providing the platform for funding. The medical record documents the activities performed and the resources used during a patient’s episode of care. Case mix funding, clinical codes and case mixed groups all assist to reflect the patient’s acuity and are funded at a higher rate than patients with lower complexity.

It is crucial that medical records accurately reflect the level of patient acuity, and the hospital’s true patient complexity, so the facility can be funded appropriately for the level of care that is provided.

Summary

A clinical documentation program will address the quality of patient’s care, quality and outcome metrics, statistics and research, which affect all Canadians. Understanding the deficiencies in documentation and/or coding within a healthcare organization is the first step in identifying the need and requirements for clinical documentation improvement. The next steps can then be initiated to ensure proper education, engagement and process. Ultimately, the goal is improved healthcare.

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Ray Simkus wrote:

Posted 2019/02/26 at 12:36 PM EST