From the May 2011 issue of HealthCare Business News magazine
Improving clinical documentation programs
The immediate industry reaction will be to leverage CDI programs. While these programs have demonstrated their usefulness, the industry’s transition to ICD-10 will call for program changes to better align CDI operations with the new coding infrastructure. This will require resources for planning and strategy, as well as for training, implementation and operation.
CDI programs have improved overall documentation quality and affecting Case Mix Index with demonstrated enhancements to revenues. Typically, CDI programs focus training for physicians and coding and case management staff, and establishing processes to manage and track physician queries. They rely heavily on trained specialists to monitor physician documentation continuously and to intervene when necessary so there are no informational gaps.
The success of any CDI program depends on physicians’ acceptance and willingness to respond to CDI staff queries for more information. Unfortunately, several informal surveys and industry reviews suggest physicians view these queries as highly disruptive to their workflow and, as a result, are inclined to ignore them. Furthermore, while the goal is to achieve concurrent queries (e.g., during a hospital stay), some may arrive after the physician has already signed the chart. In these instances, the physicians are less likely to alter their notes, further reducing the effectiveness of CDI initiatives.
As we transition to ICD-10, a great deal of information might be lost from physician documentation. This will result in a drastic increase in the volume and frequency of physician queries by CDI specialists, leading to increased disruption in physicians’ workflow and, potentially, greater frustration for all.
So, can CDI programs alone meet the challenge for physicians and help facilities in the transition to ICD-10? The answer is a qualified yes, if organizations apply sufficient human, financial and technical resources and capture enough of physicians’ time to accommodate an increase in documentation.
Computer-based automated systems may hold the answer to ICD-10
In many industries, computerized expert systems have served successfully as automated assistants, executing tedious and repetitive tasks while human experts focus on creative work. Such technologies are quickly becoming indispensable.
For example, computer-assisted editing is another name for the commonly used spell-checkers in most popular word processing programs. In health care, computer-assisted detection helps radiologists find miniscule lesions in breast images to help increase screening sensitivity and accuracy. Computer-assisted surgery uses 3-D imaging and virtual reality tools to facilitate pre-surgical planning and to guide or perform surgical interventions.
