Clinical Documentation Matters

Reading through the contest entries for the Biggest CDI Challenge, it was easy to see a trend, a common theme for most of the submissions.  Most entrants talked about the problems they had getting physicians to attend CDI training sessions or responding to queries.  Many talked about the lengths they went through to get physicians' attention on the topic of clinical documentation.  One of the winning entries used the phrase "permanently modifying physician behavior" as a goal.  At the core of all of these challenges is the same question, "How do we get physicians to care about clinical documentation practices?" 

For those of you who have been following the contest and/or who submitted entries, I would like to thank you for your contributions and support of high quality clinical documentation practices!  I have selected the winners and have notified them today. I am waiting for their replies to my email notification to make the announcment on the blog, so you should hear more about the results in a day or two. 

During one of the pilot studies for the CAMP Method CDI Training studies, a group of 16 physicians at a suburban Philadelphia hospital agreed to be ginea pigs for the program design.  As a first step, I asked them to take the pre-test, which would rate their pre-existing knowledge of clinical documentation.  At one point, I noticed pained looks on the faces of most of the physicians.

Years ago, when clinical documentation improvement programs first appeared as "DRG Optimization Programs", I heard a consultant describe the issue that most hospitals faced as one of "underdocumentation" by physicians. 

My son John was recently admitted to UCLA hospital as an outpatient for an epidural injection for what the doctor described would be a way to decrease his back pain from a bulding disc due to a basball injury - and what John hoped would be a way to eliminate it.  As it turned out, the results were much closer to John's hope than the physician's promise - but in retrospect, she was doing a great job of what all "good" consultants would call managing patient expectations.   It also turns out that this was only part of the patient-centered care approach that we experienced at UCLA.

With the 44,000 dollar per employed physician ARRA dollars available for hospitals who meet EHR meaningful use criteria, the acquisition of physician practices by hospitals is on the rise. Don't purchase a practice until you've assessed the documentation practices.

The Patient's Bill of Rights was passed during the Clinton Administration.  Although the bill only applies directly to Medicare patients, most hospitals have adopted their own - and post it throughout the hospital as well as on their website.  Two provisions in the bill relate directly to clinical documentation.

When I was writing 7 Steps to Your Best Possible Healthcare, I wanted to understand whether there was something that patients with positive healthcare outcomes had in common, so I asked them.  And, over 2,000 healthcare consumers answered my online request.