Jump Start Your Clinical Documentation Improvement Program with Meta's eCDI application...Part 1                               Go to Part 2

The CDI Process Today

For many facilities today, the CDI process is as follows:

• The clinical documentation improvement specialist (CDIS) identifies his/her review caseload for the day based on specific patient criteria, such as assigned nursing unit, financial class or service area.

• The CDIS reviews the concurrent medical record, typically within 24 to 48 hours of patient admission to the hospital, and documents the review information on a hardcopy worksheet.

• The CDIS examines the record to determine whether the documentation requires additional clarification or specificity from the physician.

• If the documentation in the record includes ambiguous, unclear or contradictory information, the CDIS initiates a written or verbal query to the physician to obtain additional documentation and/or clarification.

• The CDIS awaits the response from the physician. The query may go unanswered if the physician is unavailable or simply does not respond.

CDI Process Challenges

For many facilities, one major challenge is the cumbersome, manual processes for identifying cases for daily reviews. Clinical documentation improvement specialists often spend valuable time sorting through hardcopy census reports, manually highlighting appropriate cases based on specific patient criteria.

Once case reviews are underway, the physician query process can present some of the most daunting challenges in the CDI program. Despite the good intentions of the various stakeholders—and the acknowledged impact on documentation quality and hospital reimbursement resulting from unanswered queries—there are numerous reasons why so many hospitals experience problems with physician queries.

• Lack of time and resources required to create non-leading, succinct queries that will elicit necessary responses from physicians. Facilities may not have established language for queries, so CDI staff are required to create a query from scratch each time. Other facilities have hardcopy query template forms that are not readily available to the CDIS, creating an inefficient query generation process.

• Inaccessibility of physicians. CDI staff, HIM staff, and physicians may all be on different time schedules, making it difficult to locate the physician for questions regarding documentation. Physicians also may not have the ability to answer queries remotely or electronically.

• Excessive time required for ongoing follow-up with physicians to ensure that query responses are received. Verbal query discussions often require additional follow-up to obtain the necessary documentation in the medical record, producing an inefficient "back and forth" communication process.

• Inability to reconcile the concurrent queries initiated by CDIS upon patient discharge. Queries that were created during the patient stay that go unanswered often are dropped post discharge because HIM staff do not have the required information to follow-up or close the query.

Additional challenges for the CDI program include:

• Lack of system integration. DRG identification often has to be done manually, and CDI staff will not have the ability to compare various coding/DRG scenarios.

• Lack of appropriate management tools needed for tracking, monitoring and reporting the CDI process. Management reports are difficult to compile on a timely basis, as information must often be collected manually and reformatted into legible reports.

To address these issues, Meta Health Technology has developed an eCDI application that enables healthcare facilities to more effectively manage their Clinical Documentation Improvement initiatives. See Part 2…