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CDI Insights

Achieving Feasibility in CDI

Physician wish list meets organizational capabilities.

Welcome to CDI Insights, a bimonthly blog designed exclusively for HIM and CDI professionals serving on clinical documentation improvement teams or leading CDI programs. CDI Insights provides valuable advice on improving CDI effectiveness from three perspectives-physician, information technology (IT) and health information management (HIM).

This column addresses across-the-board CDI challenges by focusing on one specific challenge within each bimonthly column. This month's collaboration explores how to balance physician "wants" with IT and HIM "needs."

DR. FEE: At the 2014 AHIMA National Convention, a physician focus group was convened with one goal in mind-to foster a collaborative relationship where physician involvement is mutually beneficial rather than strictly based upon regulatory or organizational capabilities. Some physician requests are  feasible for healthcare organizations-some are not.  

Here is the short list of what physicians want with regard to clinical documentation:

  • Help us make our clinical documentation more productive and efficient.
  • Help us learn so we don't have to see the same queries over and over again. Educate us at the time of the query with embedded links to additional information, resources and medical criteria.
  • Don't create extra steps within our clinical documentation workflow.
  • Make the query process mutually serving. Help my practice, not just your hospital.

BONNEY: Wow Dr. Fee, that's quite the list. The challenge from a hospital's IT and HIM perspective is how to address physician "wants" with current system, workflow and staffing capabilities. Let's dive into your first two wish list items and explore potential ways that hospitals can help support their physicians.  

No.1: Make clinical documentation more productive and efficient.

Doctors want easier ways to document their encounters. Many physicians report that EHRs' template-based documentation takes longer and loses the narrative story of the patient. HIM agrees. We also admit that EHR-based documents are more difficult to review and use for coding, quality and other downstream functions. 

There are three ways hospitals can make their EHR template-based documentation easier for physicians to use:  

  1. IT and HIM professionals should team up with their physicians and EHR vendors to re-engineer documentation templates with "usability" in mind. Many EHRs were rapidly implemented to meet Meaningful Use initiatives with minimal regard to physician-friendliness. Now is the time for hospitals to ensure EHRs are easier for physicians to use. 
  2. Hospitals should also provide physicians with multiple, speech-driven documentation options. Speech integrated within EHR-based templates optimizes physician productivity while also delivering discrete data to the EHR when coupled with natural language processing (NLP).
  3. Finally, hospitals can layer natural language processing (NLP) technology atop dictated, text-based documents to flag important key words and phrases in each report. The CDI software then triggers real-time reminders for documentation gaps (nonspecific or incomplete). Similar to computer-assisted coding, this concept is termed "computer-assisted CDI" and is now offered by a growing number of HCIT, NLP and transcription vendors.  

No. 2: Help us learn. Educate us at the time of query.  

Achieving Feasibility in CDIPhysicians despise wasted effort. They want to learn from each query so they don't see the same question over and over again.

HIM and CDI professionals who repeatedly serve up the same queries alienate physicians and fail to achieve the overall objective-improving clinical documentation for physician, hospital and patient. Real-time education provides a practical solution-and promotes partnership. Here are two ways to begin: 

  • Hospitals should facilitate an educational process by including informational hyperlinks, online resources and clinical references within each query. The extent to which hospitals can delivery real-time education will be determined by their technological capabilities.
  • HIM and CDI professionals can also serve as human intermediaries, offering to help physicians at the time of query, not after the fact. Again, the availability of these resources is driven by the organization's staffing capacity. 

DR. FEE: Implementing all of these physician supports would go a long way in making physician documentation more productive and efficient. Here is one specific example:

Abnormal Creatinine, Acute Kidney Injury or Chronic Kidney Disease?
Patient is admitted with a creatinine of 1.5 mg/dL, diagnosed with a urinary tract infection, and administered IV fluids. The creatinine drops to .9 mg/dL. In the clinical documentation, the physician simply states "abnormal creatinine." Based on the nonspecific phrase of "abnormal creatinine," the CDI software could send an alert to the physician and CDI specialist asking for the underlying cause.

Furthermore, the automated query could educate the physician by embedding a link to the clinical documentation criteria for both acute kidney injury and chronic kidney disease. The education could reside within the organization's EHR physician reference database or an outside knowledge source.

DR. FEE: To really engage physicians, we could make sure the query, link and educational information are properly displayed on a mobile device.

BONNEY: Great idea, Dr. Fee and that provides instant access to support documentation efforts.

DR. FEE: And finally, don't forget to attach medical CMEs to the education! Think of it as an equation: Query + Education + Reward = Improved Clinical Documentation

Taking the First Step
The first step of any journey begins with a solid idea. We've laid out several in this month's installment of CDI Insights.

Visit our column in April 2015 when we discuss how to target the most important clinical diagnoses and surgical procedures for your CDI efforts.

Steve Bonney is responsible for business development and product strategy at RecordsOne. He is a national author and speaker on the use of natural language processing technology in healthcare. He works hand-in-hand with hospitals to identify new and innovative uses for NLP within coding, clinical documentation improvement, quality reporting and reimbursement. Bonney is an active member of AHIMA, ACDIS, HIMSS and WEDI.

James P. Fee, MD, CCS, CCDS, is vice president of Huff DRG Review.  He is board certified in Internal Medicine and Pediatrics and maintains a clinical practice in hospital medicine.  Dr. Fee is an AHIMA-approved ICD-10-CM/PCS trainer and serves in a consultative role regarding DRG management and ICD-9-CM validation.

This article was one of our most popular of 2015. See the full list here.


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