Integrity: The Missing Component in CDI

Integrity means moving from a retroactive, transactional approach to one that documentations patient care.

There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for a solid definition of “integrity,” a Huffington Post article on the topic really caught my attention, and is certainly worthy of discussion (The True Meaning of Integrity). Here is the piece, and the direction I am focusing upon as relates to the profession of clinical documentation improvement:

• The definition of integrity: a “concept of consistency of actions, values, methods, measures, principles, expectations, and outcomes. In ethics, integrity is regarded as the honesty and truthfulness or accuracy of one’s actions.”

The author calls out three missed words, or what I refer to as misconceptions, with this definition: consistency, honesty, and truthfulness. Let’s examine and discuss how the CDI profession is overlooking these three definitions.

Putting Integrity in Proper Perspective in CDI
The purpose of CDI programs is to affect positive change in overall behavioral patterns of documentation among physicians for all the right reasons, including contributing to patient care, improvement, and quality. Clinical documentation improvement specialists are charged with reviewing the medical record, identifying opportunities for clarifying, solidifying medical record documentation, and issuing a written or verbal query when clinically appropriate.

According to the American Health Information Management Association (AHIMA) Guidelines for Achieving a Compliant Query Practice (2016 Update), the generation of a query should be considered when the health record documentation:

• Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent;

• Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis;

• Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure;

• Provides a diagnosis without underlying clinical validation; or

• Is unclear for present-on-admission indicator assignment

Clinical documentation improvement specialists are held to a code of ethics in their practice, as promulgated by AHIMA and the Association of Clinical Documentation Improvement Specialists (ACDIS). Leading queries are not permitted, and conversation with clinicians is not to include or infer reference to documentation and its direct relationship to reimbursement (i.e., “if you document the clinical condition this way, the hospital will make this much more.” The underlying CDI foundational processes in and of themselves, consisting of the query process for clarification of diagnoses, is a formidable barrier to the profession truly transitioning to clinical documentation integrity versus clinical documentation improvement. In general, most CDI specialists and programs are consistent in generating queries to clarify diagnoses in a compliant fashion, although I am seeing firsthand some engaging in questionable query practices, and coaching of physicians to capture a diagnosis in a manner that adds reimbursement to the case through a major complication and comorbidity (MCC) capture with disregard for the clinical presentation and scenario. Case in point: coaching physicians to document toxic encephalopathy in a patient who presents with altered mental status related to excessive drinking and presents to the emergency department for care. Inappropriate coaching of physicians to report unsubstantiated clinical diagnoses, translating into ICD-10 codes for reimbursement enhancement, flies in the face of behavioral integrity.

Why does the query process present a formidable challenge for achieving integrity in documentation? The answer lies in the focus of CDI, with key performance indicators (KPIs) that fail to measure and correlate with the achievement of documentation integrity.

We are all too familiar with these KPIs, including but not limited to the number of queries generated, number of records reviewed, physician response rate, physician agreement rate, CC/MCC capture rate, case-mix increase, DRG reconciliation rate, etc. Inarguably, these KPIs have no direct correlation with improvement in the quality and completeness of documentation that best serves the patient, the physicians, and all relevant healthcare stakeholders in doing right for patient care.

All one must do to validate this assertion is pick up any record and examine the quality and consistency of documentation, or simply review most medical necessity denials; incomplete, insufficient, and simply poor physician documentation is consistently the culprit. I submit to the CDI profession whether the acronym of “clinical documentation improvement” (or for that matter, “integrity”) is appropriate, given the state of documentation and communication of patient care at most facilities, this despite the fact that the profession has been in existence for 10-plus years now.

Achieving Integrity: A Better Approach
Achieving documentation integrity in the record requires emergent wholesale changes in current CDI processes. Business as usual, represented by an unrelenting focus upon the query process to solidify and capture diagnoses for reimbursement purposes, with ongoing key performance indicators being used as measures of gauging success, precludes achievement of clinical documentation integrity. “Integrity,” as discussed at the onset of this article, is synonymous with honesty, consistency, and truthfulness.

The electronic health record (EHR), with all its inherent features, such as copying and pasting, carrying forwards, and dropdown menus, coupled with the overwhelming administrative burdens posed by the EHR, promote generation of documentation that is not clear, concise, or consistent. In short, the medical record falls short in reference to consistency, honesty, and truthfulness in painting a true picture of the patient story, all germane to the practice of medicine.

As CDI specialists, we have all experienced inaccurate progress notes produced through inappropriate copying and pasting, inconsistencies in documentation between the physical exam and assessment and plan of care, and inclusion of diagnoses in the assessment that have been ruled out or resolved days before. These patterns of documentation in and of themselves do not equate to “integrity.”

The wholesale changes in CDI current processes I am advocating for require a commitment to total transformation of present-day CDI activities. The CDI profession must recognize the requirement to acquire the skill sets, core competencies, and knowledge base to enable us to carry out a holistic chart review and identify insufficiencies and incomplete documentation beyond just equating clinical indicators, findings, and treatments for purposes of generating a query for reimbursement. This requires defining facility-specific standards of documentation that the program aims to achieve as an integral part of attaining high-value patient care: the right care at the right time in the right setting for the right reason with the right documentation. I always wonder how CDI can bill itself as being in the business of clinical documentation improvement when the profession hasn’t defined what constitutes “documentation improvement.” The adage applies: how do you know if you reached a specific destination if you don’t know where you are going?

Final Thought
I want to leave you with this final thought that I found on the High Value Practice Academic Alliance website outlining the founding principles of the organization. (HVPAA Principles)

The Hippocratic Oath includes a commitment to “remember that…illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”  

As such, HVPAA was founded on the following principles:

1. Medicine is a public trust, and to maintain the trust that the public places in physicians and other healthcare workers, medical providers have a responsibility to improve value in healthcare.

2. Cross-institutional collaboration is essential to effectively improve healthcare value on a national scale.

3. Outcomes research must ensure that refinements maintain, or ideally, improve providers’ ability to effectively diagnose and treat patients.

4. Engaging medical students, resident physicians, and fellows in this work is key to creating lasting improvements in practice.

The CDI profession can refer to itself as “clinical documentation integrity” provided that it recognizes the immediate need to switch from a retroactive, repetitive, transactional approach to one embracing and incorporating proactivity in moving the needle of documentation of communication of patient care.

By approaching record reviews and standards of documentation in this fashion, we can truly help physicians adhere to the Hippocratic Oath, as referenced above. I submit to all in the CDI profession for a call to action.