When MEDICARESeverity (MS-) DRGs came into effect in October 2007, hospitals discovered an unexpected clinical documentation gap that impacted their bottom line. While doctors traditionally write clinically oriented notes that reflect and communicate their medical assessments and plans. the new features of MS-DRGs require a medical record with greater diagnostic specificity. The consequences of this gap have led to significant reimbursement issues and a potential loss of revenues. In response, many hospitals have instituted Clinical Document Improvement (CDI) programs, and a new specialty emerged, the Clinical Documentation Specialist. these initiatives have traditionally been paper-based, and often prominently feature the use of a “sticky note” on the chart to alert the doctor to the need for a clarification or additional information. Tracking and reporting tool s have been created to help manage and demonstrate the financial impact of the CDI program. The young field of CDI is already evolving beyond its spreadsheet-driven roots. As fully electronic medical records become a reality, some CDI-supporting software programs have begun to offer a simple H7 feed for admission data and patient demographics. But to comprehensively integrate fully into the electronics document environment, the software will also need to be able to send documents back to the EMR, receive and understand additional data feeds from laboratory results, medication lists and structured documents and return structured data (for example in the HL7 Clinical Document Architecture format). DI focuses on improving the documentation in progress notes. Since more and more of these are being done electronically, CDI software should be able to directly create or feed progress notes as well as the electronic problem list. As if this was not a big enough challenge, ther is now a growing recognition that CDI has a role beyond simple revenue enhancement. Accurate and complete physician documentation is needed as the foundation for accurate coding, and ithat in turn is essential for a wide variety of initiatives related to healthcare economics and reform. These include:
The growing attention being paid to clinical documentation has direct implications for healthcare information technology planning and deployment. Rather than simply recreating what we already do today with notes and spreadsheets, the advanced use of existing and emerging technologies will be required to allow for totally new workflows, efficiencies, integration, reporting and analysis. This, in turn, will result in more complete and accurate documentation and pave the way for continued improvement in the delivery of quality medical care. Clinical documentation improvement is definitely not just for reimbursement anymore
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