Clinical Documentation Matters

Breakfast is the feedback of champions.  I wish I could take credit for this line, but it belongs to Ken Blanchard, author of The One Minute Manager, among many other widely used management books.  Blanchard, like most good managers, learned early in his career that specific, frequent, constructive feedback provided to employees produces better results than no feedback or "general" feedback. So, in other words, your're more likely to see improved performance if you let Tom know that you appreciated the extra work he did putting together a powerpoint for a recent physician CDI presentation - specifically noting that the examples he used were clear and directly on target, than just saying, "great job,Tom!"  And, you're more likely to get a good response if you provide positive as well as critical feedback.  Blanchard took this concept further in Servant Leader by describing how mangers and other leaders should also seek out feedback from peers, subordinates, and others to improve their own performance. Bottom line is, EVERYBODY needs feedback and, if we all got it frequently, and in a manner that is specific to our own actions, we'd be CHAMPIONS - at least according to Blanchard.  So, physicians in relationship to their clinical documentation are included in this claim.  I have seen physicians respond positively to CDI feedback quite frequently with resident CDI training.  And, when given the opportunity to provide specific feedback to attendings, have seen it with them as well.....the review of 5 to 10 services or progress notes per physician that is performed in many academic medical centers for both CDI and compliance purposes is a good example.  Of course, this activity only meets the "Feedback is the breakfast of champions" criteria if, after the review, any documentation deficiencies that were identified by the reviewer are discussed one-on-one with the physician.  Sure, detailed reports can be helpful and, for operational and compliance purposes they're necessary.  But let's face it, when we talk about feedback we're talking about an interaction that is specific to the physician and allows the physician to comment and ask questions - a report just doesn't make the mark.  As most of you already know, the challenge with providing specific clinical documentation feedback to physicians is the appropriate selection of the "messenger" - for the right result, the messenger must be someone whom the physician perceives as knowledgeable and confident in his/her delivery....in other words, an expert in both the technical components of the information being delivered as well as the delivery (i.e. the communication) itself. 

We all need feedback....that includes me! So, part of my purpose in spotlighting Ken Blanchard in today's blog is to ask you all for feedback to any blog entry where you feel you can or want to make a contribution.  Your entries will not only benefit me, but all of our readers.  If you want to comment, you must be logged on as a user....if you are not already a registered user, just sign up on the home page - it's free!  And, registered users get access to alot of useful resources that you can use both in your CDI programs and personally....also, pass on the links for blog entries that you think others might be interested in. The more CDI and other interested professionals we get linked in and providing feedback on the blog.....the sooner we'll all be CHAMPIONS!!!!

In 2009, I wrote a book for AHIMA called Clinical Documentation Improvement:  Achieving Excellence. Have you read it?  It’s pretty good.  And, in all honesty it’s good because of the 200 hospitals who allowed me and my teams at HP3 and then Navigant Consulting in their doors to implement CDI Programs.  These hospitals and their CDI teams (many of you who are reading this blog know who you are!) provided the raw material and eventually the refined products of clinical documentation that allowed me to compile a CDI operations-type manual.  You can find it at  https://www.ahimastore.org/ProductDetailBooks.aspx?ProductID=14182 . Also in 2009,  with the help of Ginger McQueen and David Moore, my long-time esteemed colleagues, I translated my doctoral dissertation research on clinical documentation improvement training into a 2-volume book called A Compelling Case for Clinical Documentation  - using the CAMP Method (www.acompellingcaseforcdi.com ) and started the Clinical Documentation Matters website.  My intention was to make as many solid resources about high quality clinical documentation available to hospitals, healthcare systems, and physicians as possible. With the help of my physician expert friend and co-instructor Dr. Ian Diener, we turned some strong theory into practical applications and trained hundreds of people on the CAMP Method in 2009. 

AHIMA announced the appointment of Alan Dowling, PhD as its new CEO earlier this month.  If you have not already listened to his brief interview on YouTube, it may be worth your time to do so:   http://www.youtube.com/watch?v=b_EAThJj0xM.  With an impressive background in healthcare management and information systems (he earned his PhD from MIT!), it seems clear that the EHR is a top priority for the organization moving forward - important enough to result in an appointment that values education and experience over the AHIMA credential - though Dr. Dowling is an AHIMA member, he does not hold any of the 7 current AHIMA credentials….more importantly, although AHIMA may or may not be the national professional association of choice for the CDI profession (depending on your perspective), its strategic vision, supported by 55,000 members, is a significant influence on the structure, function and future of clinical documentation.   So, what does that mean for CDI professionals? 

The patient’s rights and interest in their own health information could be one of the strongest rationales for physicians’ compliance with clinical documentation requirements.  In patient education sessions, I have experienced the interest and concern that some patients have for their health information.  Some patients have even exercised their HIPAA rights to request modifications to their records – sometimes because documentation was not legible, sometimes because it was incomplete, and yet other times because the patients did not agree with subjective interpretations of healthcare providers that were documented in the patient’s record – one that comes to mind is the physician who documented that the patient was, “unkempt and obese”.  The patient complaint ended in a partial retraction of the documented statement.  One successful approach in physician CDI training is to ask physicians, when they are reading the sample records you are using for training (you are doing this, right?  If not,  you may want to read about the “M” for mastery in the CAMP Method on www.acompellingcaseforcdi.com ) – anyway, ask the physicians to view the records as their own, or better yet, as their children’s records.  Would they be satisfied with the documentation if the record belonged to them or their family member? Just asking the question can create a paradigm shift…..I’ve seen it happen, maybe you will as well….

A few months ago I had the pleasure of taking a few of the Harvard Medical School Continuing Medical Education online courses.  The courses were on the topics of how physicians should communicate with patients about weight control concerns as well as whether (and how) they should recommend complementary medicine therapies to their patients.  I was fascinated with the efficiency of the process as well as the amount of information I was able to retain over time. In most cases, I was able to complete the 1 hour CME program in under an hour – not by much – but they were clearly time savers – which to anyone is a good investment. The programs were like most online learning systems where you read a few paragraphs and/or a case study and then answer 5 or 6 multiple choice questions – and repeat this process 5 to 6 times.  The Harvard online CMEs were a bit pricey in some cases – for each 1 hour CE the price was between 80 and 100 dollars – and that price only covered my 1 hour session.  So while the investment to an individual might look economical – for a hospital potentially looking to train their entire medical staff – these type of CMEs are cost prohibitive –even with deep discounts of 50 percent, for a medical staff of 300 to 400, the cost would be up to 20 thousand dollars! So, that got me thinking about more cost effective ways to deliver the CAMP Method CDI training for physicians….which is how we came up with the idea to make the initial 90 minute CDI program web-based and downloadable and only charge 79 dollars for unlimited access – so hospitals can train the entire medical staff using this resource.  Many of you have purchased that program, which I call Basic Coding and Clinical Documentation for Physicians – which is great, but I still keep thinking about the Harvard CME’s – and wondering whether physicians would respond better to a Harvard-type model.  I am researching the cost and will keep you all posted via the blog about progress in this area….in the meantime, if any of you have strong feelings one way or the other about on-line training for your medical staff, please email directly with your thoughts at This e-mail address is being protected from spambots. You need JavaScript enabled to view it  or leave a comment below.

By far the most common question that CDI Specialists and managers ask me at the end of any presentation about clinical documentation is for clarification about a leading query….what is a leading query?  Can a leading query ever be asked?  Is there a difference between a query asked by a coder retrospectively versus a clinician concurrently?  After many years of practicing clinical documentation implementation and pondering query-related questions, I have come to the conclusion that there is no absolute answer to most of these questions.  At one time, the issue so consumed me that I actually considered writing an entire book entitled, Anatomy of a Query.  In a moment of insanity, I even created an outline for the book.  And when I realized that my obsession had gotten the best of me, I saved the outline in a word file and moved on with a quasi-normal life. Just a few minutes ago, I did a “search” on my C drive for any document with the word query in the title.  Just to give you an idea of how query-obsessed I am, the search returned over 6,000 documents….one of them was the original outline for the proposed book. Here are some of the contents of that outline:

With 260 plus entries to go and no outline to steer the blogging ship, I was a bit concerned about what to blog about first…..then, I realized that it’s best to start at the beginning – with the patient and the patient’s medical record – the source of all clinical documentation.  For the last few years, I have begun to add healthcare consumer education to the work I have done with healthcare providers – partially to get a handle on the patient’s perspective and be able to bring this to the table during provider training and partially because, after all, the clinical documentation we all work so hard to improve is indeed all about the patient! During the education sessions, when I am describing the patient’s right to his health information as well as the content of his medical record, I often ask the attendees to think about the care with which their financial data is managed by their bank – as well as how they have carefully protected access to all of their financial transactions.  Then, I tell them to think about their health information and the fact that it too is protected with the same rigor as their financial information…..and, that someday – hopefully in the not too distant future under the Obama administration – they will have the same kind of access to their health information on line as they do with their financial information.  Then I go on to talk about the content of the record and how each of us should read our records – and, further if we don’t understand the information, or agree with it – per HIPAA – ask the provider to explain and/or modify information to ensure accuracy. So, the question that every provider needs to ask themselves is just this….”do we ensure the qualitative integrity of patient health information with the same level of rigor that banks protect financial information?”  This question is the most significant rationale for a CDI program…..