Survey Results- Primary Challenges in CDI

Top Gun CDI Survey Results- Number One Challenge in CDI Impacting Optimal Performance

Top Gun Audit School of which I am a Co-Founder recently shared a survey with CDI professionals in the interest of gaining a keen understanding of the top challenges CDI specialists face in their quest to enhance the integrity of medical record documentation. The survey question was as follows:

·      What specific area of Clinical Documentation Improvement poses the most challenges to achieve meaningful and sustainable improvement in physician documentation?

Given Responses & Results

·      Lack of physician engagement and participation in CDI initiatives-                       52%

·      Too much focus upon CC/MCC capture with little time and energy devoted to anything else                                                                                                             10%

·       Too much focus upon task-based activities represented by the query process        11%

·      Too much emphasis measuring performance                                                          20%

·      Other                                                                                                                         14%

Discussion of Results

Let’s take a look at the responses from the CDI professionals who completed the survey with addition of my thoughts and comments. Fifty-two percent of the respondents indicated there top CDI challenge centered around lack of physician engagement in their CDI initiatives, something not at all not surprising to me. As a long time physician champion and advocate for clinical documentation embracing the notion and conviction that CDI serves as facilitators in communication in patient care versus chart police looking for diagnoses through the query process, the CDI profession must come to terms that the current CDI focus and emphasis upon task-based activities rooted in reimbursement optimization are not situated to ever engage physicians. Physicians by the very nature of medicine with all its competing forces for physician’s precious time and energy are stretched very thin; now add the burden of charting in the electronic health record, constant interactions with care team members and relevant stakeholder and then overlay CDI repetitive, reactionary and transactional queries that physician receive in their email boxes and it is simply not hard to understand and appreciate why physicians are generally not fully engaged in CDI initiatives. Given the extraordinary time and extraordinary effect the country is currently facing with the Coronavirus, there is no time like the present to address lack of real physician engagement in most programs. Physician engagement must be defined and judged well beyond physician query response and agreement rate given the fact physician queries are made part of the chart incompletion deficiency process whereby physicians can be suspended for not completing their queries. I find this hard to characterize as true physician engagement, more like mandated physician engagement. Fundamental to fully engaging physicians in wanting to learn about, become more proficient in and incorporate into their daily practice of medicine best practice standards and principles of documentation that best communicate patient care is to transform CDI from one of tendency towards adversarial physician relationship to one of coach and guide Equipping ourselves with the knowledge and skill sets to be able to identify material insufficiencies in the medical record, provide feedback to physicians and positively address with the physician proactively is the hallmark of serving as a coach and guide to physicians, adding significant value to the CDI profession

Forty-one percent of respondents indicated that there was too much focus upon CC/MCC capture with little time and energy devoted to anything else or too much focus upon task-based activities represented by the query process or too much emphasis upon measuring performance. These responses can be categorized into one major CDI characteristic of present CDI processes that significantly detracts from optimal sustainable CDI performance, sacrificing short term gain for sustainable long-term performance. Inarguably, current CDI processes are primarily task based predicated upon the retrospective query process. Present day Key Performance Indicators evolving around the query process crowd out the ability of CDI staff to serve as facilitators of complete and accurate physician documentation. KPIs that promote narrowly defined task-based activities such as number of charts reviewed, number of queries issued, number of CC/MCCs captured through the query process fail to correlate with and bear no resemblance to actual achievement of physician documentation improvement/integrity. This beckons the reasonable question of why we are utilizing KPIs that direct CDI task-based activities when they do not support and facilitate actual CDI processes that lend themselves to drive achievement of meaningful improvement in physician documentation. I submit to all CDI Leadership the immediate need to evaluate current KPIs, rejecting the notion that current KPIs are reasonable standards for measuring CDI program performance. The status quo is simply not an option if you are committed to optimal CDI performance from a quality of documentation supporting quality patient care perspective that is closely aligned and integrated with a high performing revenue cycle. I also call on CDI Leadership to recognize that more valid and reliable KPIs consist of measures of medical necessity and clinical validation denials as well as DRG and level of care downgrades are available and I am happy to share a list of alternate KPIs I have developed for consideration as complementary to current KPIs.

The “Other” category of survey responses includes elements that demonstrate CDI professionals desire to contribute much more to the improvement and integrity of physician documentation on behalf of the patient, the physician and all relevant healthcare stakeholders. Several responses from the Other category include 1) Too much focus upon impact rate quotas as individual performance metrics; 2) Not enough focus on medical necessity; 3) Too much emphasis upon direct revenue queries; 4) Get rid of the useless KPIs that measure performance; and 5) Educating providers on clinical validation/significance and criteria necessary to document a certain diagnoses.

Closing Thoughts

The first of several Top Gun Audit School CDI surveys planned identified the most challenging areas CDI currently face in performing their crucial role of working with physicians and other providers to achieve real improvement and integrity of physician documentation. Current CDI processes must be redesigned and repositioned to further continued growth and evolution of the CDI profession. Complacency and maintenance of the status quo is not a viable option given the increased need for complete and accurate medical record documentation associated with evolving payment models, financial risk sharing payer contracts such as Shared Savings Programs and disease entity bundled payments and an increasing emphasis upon medical necessity and increasing denials issued by payers. The need for CDI Leadership and all CDI professionals to embrace holistically defined CDI cannot be overemphasized. Present CDI processes have outlived their shelf loaf, providing day old bread quality while contributing to unnecessary costly denials.