Accurate clinical documentation is not just a matter of duty and compliance; it's about enhancing the communication of patient care and severity with sound documentation practices, thereby ensuring the accuracy of data gleaned from health records. The journey toward documentation improvement is multifaceted, involving stages of development that each healthcare organization must navigate. Before getting into the four practical steps to improving physician’s clinical documentation, let’s ground ourselves with the evolutionary stages of clinical documentation initiatives:

• Stage One: Focus predominantly if not entirely on accurately capturing Complications or Comorbidities (CC) and Major Complications or Comorbidities (MCC). This stage was fundamental in improving severity capture via the DRG billing system.
• Stage Two: Scope expands to include comprehensive documentation and reporting of patient severity beyond CCs and MCCs. This critical stage highlights the need for greater physician involvement and challenges the traditional query process, aiming to reduce physician burnout through strategic engagement.
• Stage Three: Prompted by the demands of the current post COVID landscape, stage 3 emphasizes efficiency and sustainability in documentation practices and performance. This stage is about achieving long-term success without over-relying on external consultants, minimizing the reliance on the query process, and creating an ownership mentality for providers when it comes to clinical documentation.

Through this progression, the need for a paradigm shift in documentation integrity ownership becomes evident. Success and adaptation to the demands of the different stages are contingent upon an organization's commitment to advancing to and embracing the principles of Stage Three. Below are key considerations that set up a strong foundation for thriving in Stage Three.

1. Executive Buy-in

A crucial first step is executive buy-in and stewardship. The involvement of top executive decision makers is critical in setting expectations, providing support, and modeling the value of accurate documentation. However, to achieve this, executives must have access to reliable data that instills confidence in the opportunities identified and the success of what should be a data driven initiative. Traditional metrics like query response rates, CC/MCC capture rates, including any opportunities identified by benchmarking alone, fall short of providing this. Watch our webinar "Rethinking CDI as a Healthcare Executive" to learn more!

2. Thoughtful Incentivization

While incentives can motivate improvements in documentation practices, it’s crucial that these incentives are designed to foster genuine enhancement of documentation quality, rather than mere compliance with answering more queries. Metrics selected to incentivize physicians in documentation improvement must be carefully chosen, since there is a risk in undermining the purpose of the initiative.

Physicians require reliable metrics that accurately reflect their documentation performance, supported by a robust patient-to-provider attribution method to ensure its validity. Additionally, they need actionable metrics that guide them on specific areas for improvement, enabling them to concentrate their efforts effectively.

3. Leverage Technology Wisely

Despite the advancements in technology, such as computer-assisted physician documentation or CDS workflow optimization tools—they ultimately do not decrease the reliance on queries since they are not designed with the intent of impacting physicians long term documentation practices. In fact, as with CAPD tools, the query period has essentially been moved to the point of initial documentation.

ClinIntell's mobile app introduces a unique and validated approach to clinical documentation improvement efforts. It allows physicians to engage with educational content on a data driven list of clinical conditions with significant opportunities for improvement within their specific inpatient population. This approach guarantees that improvement efforts are directed where they are most needed, maximizing impact while offering unparalleled ease of use for physicians.

Through the app, they can effortlessly watch a series of 3-4 informative videos, assess their understanding through quizzes, and consult standardized definitions and practical tips, all from their mobile device. This accessibility ensures that valuable resources are always within reach, facilitating a more efficient and effective approach to enhancing documentation practices.

4. Effective Use of Data

Successfully completing training on specific clinical conditions is just the first step. Equally vital is the ability of physicians to access and interpret their performance data, tracking their progress over time. This capability is key as it allows them to identify areas for improvement, whether that means adjusting their documentation strategies or revisiting educational content for a refresher.

ClinIntell’s CMI Documentation Score, a comprehensive documentation performance metric ranging from 0% to 100%, is designed to show physicians how well they align with their group's documentation standards and goals. This unique metric, underpinned by our advanced clinically expected CMI, is the sole indicator capable of evaluating severity reporting performance across levels, from the entire health system down to individual physicians.

Furthermore, our actionable clinical condition data built upon our intricate clinically expected coded rates, provides detailed insights into physicians' documentation efficacy for each condition. Distributing personalized reports keeps physicians accountable to their group's performance and goals and promotes a culture of healthy competition and dialogue by including peer performance comparisons in these reports.

5. Engage Actively

With appropriate incentives established and physicians equipped with the necessary technology and reports, it's crucial to involve them as active collaborators in the documentation improvement efforts. This involves holding physicians accountable for ongoing progress, which can be achieved through several strategies:

• Distribute monthly personalized reports to physicians participating in the program, offering them insights into their documentation performance.
• Share monthly reports at the group level with all key stakeholders, including executives, clinical leaders, CDI teams, HIM professionals, and Quality departments, to maintain transparency and collective focus on improvement goals.
• Initiate targeted conversations with physicians who require additional support, providing them with the guidance and resources needed to enhance their documentation practices.
• Foster an environment of peer learning by encouraging physicians with lower performance metrics to engage in dialogue with their higher-performing counterparts, facilitating knowledge exchange and mentorship.

Adopting active learning approaches over passive ones is a transformative step towards embedding sustainable enhancements in documentation practices, ensuring lasting benefits for both healthcare providers and patients.

The journey to improve clinical documentation centers on teaching physicians to document high-impact clinical conditions correctly from the outset, reducing the need for subsequent queries which mitigates burnout. Leadership's role in promoting accountability, along with strategic incentivization, smart technology use, and fostering an active engagement culture, is crucial. This collective effort leads to a natural progression towards better patient care, emphasizing the importance of getting documentation right the first time.

Click here to learn more about ClinIntell’s Data-Driven Severity Documentation Mobile Application.