Computer-Assisted Clinical Documentation Improvement to Support Quality Initiatives
Jan 16, 2017
by Dr. Jon Elion

Today, there is an increasing focus on Quality in the delivery of medical care, along with an associated alignment of Medicare reimbursement to quality measures. The measurement of quality can be directly impacted by Clinical Documentation Improvement (CDI), as failure to fully document comorbid conditions can lead to unfavorable and less accurate quality scores. Most quality measures (complications, mortality) are reported using “Observed‐to‐Expected” rates (O/E ratio). A ratio greater than 1.0 means that the observed events are occurring more often than expected. Failure to document comorbidities results in a higher ratio, and implies a lower Quality measurement. It is important to assure that the “Expected” part of quality calculations properly reflects the condition of the patient, which in turn means that complete documentation of all aspects of the medical condition is essential (not just the ones that directly impact reimbursement).

In addition to improving the quality of the clinical documentation, attention needs to be paid to coding. Coders must create a complete and accurate set of codes that correspond to all of the conditions documented, keeping in mind that quality coding impacts apparent CDI program performance and quality measures. Providers should spend time auditing and reviewing their coding practices and performance. If it’s not coded, it cannot be reimbursed or measured. But if it’s not documented, it can’t be coded.

Measuring and improving the quality of care is nothing new for hospitals who by now have figured out that it is important to track their quality scores. Unfortunately, some CDI consultants and service providers still take the narrow reimbursement-driven point of view, thereby missing opportunities to completely document all co-morbidities and conditions that may impact “Severity of Illness,” “Risk of Mortality” and other measures of Quality and Value. Recent changes in healthcare reimbursement incentives tied to quality and value have brought increasing attention to these topics.

A new trend is emerging in the hospital-based assessment and tracking of quality measures, namely the move from “retrospective quality measures” to “concurrent quality measures.” Rather than reporting on what happened at the hospital 6 months ago (for example), new computer-based methods for assessing and reporting issues related to quality and value are being implemented for use while the patient is still in the hospital.

It is convenient and logical for this functionality to exist within the software tools that support the hospital’s CDI program, as it is necessary to collect information about hospital census, patient diagnoses, procedures, etc. Unlike Computer-Assisted Coding (CAC) which tends to be an activity that begins after discharge and focus on what is on the chart, CDI, and especially Computer-Assisted CDI (CA-CDI) is brought into play during the hospitalization and focuses on what is not yet on the chart.

Some of the advantages that hospitals are finding by automation and computer assistance in the CDI process include:

  • identifying and correcting documentation deficiencies that may adversely affect quality measures before submitting data
  • disseminating alerts the the Clinical Documentation Specialists (CDS) customized for issues identified at their hospital or hospital system
  • finding the patients who qualify for data reporting as part of the CMS Core Measures program
  • measuring the impact of a CDS, the CDI program, and the various physicians in improving documentation related to Severity of Illness and Risk of Mortality

When CDI programs only pursue reimbursement, this complete documentation of comorbidities can be overlooked or missed. Many diagnoses that will impact the Risk of Mortality or Severity of Illness without changing the DRG or reimbursement. Clinical Documentation Improvement — it’s not just about reimbursement!

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