DI's present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness and effectiveness of medical record documentation. Common KPIs include number of physician queries left, number of queries responded to by the physician, number of queries responded to by the physician that captured a CC or MCC, number of queries responded to by the physician that impacted severity of illness/risk of mortality, number of charts opened and reviewed per day, etc. Examining each KPI individually as well as collectively clearly demonstrate a lack of correlation with measurable improvement in clinical documentation that best communicates the patient care provided. Measurable improvement in clinical documentation adheres to principles outlined in the American College of Physician’s Position Paper-Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper published in January of 2015. Take note of just some of the many credible points made in the article that speak to documentation:
- The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future.
- The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
- The clinical record should include the patient's story in as much detail as is required to retell the story.
Current CDI Processes-The Necessity for Reengineering
I submit to you that current processes of CDI focusing primarily upon the capture of CCs/MCCs and principal diagnosis optimization fails to address and achieve in any reasonable manner the purpose of clinical documentation as spelled out in the ACP’s Position Statement. As I have always maintained and still champion, reported diagnoses in the record must be surrounded and supported by accurate reporting and reflection of the clinical facts, clinical information and context of the particular case. This means an accurate and complete History & Physical explaining the circumstances of admission to the hospital including a concise yet encompassing History of Present Illness, Patient Chief Complaint in his/her own words, a physical exam congruent with the patient’s nature of presenting problem and the physician’s clinical judgment, a discussion of any abnormal lab values/diagnostic workup results and other pertinent findings and their relationship to the diagnosis outlined in the assessment, and a plan of care congruent with the assessment. Clinical judgment, defined by the physician’s assessment of a particular clinical scenario and the initiation of action congruent with the assessment, is fundamental to the practice of medicine and must be clear in the documentation.
Progress notes are another problematic area where CDI should be focusing its efforts and energy as well beyond mere diagnosis capture that only impacts reimbursement. We are all too familiar with progress notes that lack purpose, substance and validity with the rampant indiscriminate use of cut and paste and carry forwards. Incorrect and inaccurate information is perpetuated throughout the record with questionable contextual consistency. CDI should be promoting, educating, advocating for and achieving progress notes that meet the following conceptual characteristics:
- Factually correct
- Temporally relevant (no future tense references to procedures already done)
- Concise (no fluff; just a concise statement of the facts)
- Devoid of plagiarism
- Analytic– (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
- Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)
Encompassing Key Performance Indicator for Progress Notes
A recent article certainly worthy of reading by all CDI specialists recently published in the January 2018 Journal of Hospital Medicine is titled A Prescription for Note Bloat; An Effective Progress Note Template. The article outlines the results of a quality improvement study carried out at four major academic healthcare institutions: University of California Los Angeles (UCLA), University of California San Francisco (UCSF), University of California San Diego (UCSD), and University of Iowa. This clinical documentation quality improvement study combined brief educational conferences directed at house staff and attendings with the implementation of an electronic progress note template. The goal of the study was to determine if progress note quality can positively be impacted and achieved through brief interventions and utilization progress note templates. Note quality was measured using a general impression score; the Validated Physician Documentation Quality Instrument, 9 item version; and a competency questionnaire. What stood out and immediately came to mind was the applicableness of the Physician Documentation Quality Instrument, 9 item version as an instrument the CDI profession could potentially use as a Key Performance Indicator measuring our success in achieving sustainable improvement in clinical documentation. Here is the list of items in the instrument:
- Up-to-date: The note contains the most recent test results and recommendations.
- Accurate: The note is true. It is free of incorrect information.
- Thorough: The note is complete and documents all of the issues of importance to the patient.
- Useful: The note is extremely relevant, providing valuable information and/or analysis.
- Organized: The note is well formed and structured in a way that helps the reader understand the patient’s clinical course.
- Comprehensible: The note is clear, without ambiguity or sections that are difficult to understand.
- Succinct: The note is brief, to the point, and without redundancy.
- Synthesized: The note reflects the author’s understanding of the patient’s status and ability to provide a plan of care.
- Internally consistent: No part of the note ignores or contradicts any other part.
For scoring, one can assign 12.5 points for each item for a total of 100 points with predefined score associated with each point level achieved, i.e., 87.5 correlating to an A, etc.
Time to Rethink Our KPIs
In conclusion, there are numerous Key Performance Indicators that can possibly be used to more accurately reflect and report the achieved successes of CDI in affecting positive change in the quality and completeness of documentation including progress notes. Good documentation is a fundamental component of high-quality care. The profession alludes to the fact and wants to take credit for improving the reported quality of care in the hospital. Let’s revisit our processes of CDI in the interest of actually improving the quality of care through achievement of consistently sound principles of clinical documentation to complement our efforts at securing diagnoses and optimal reimbursement. Optimal reimbursement is not rooted in longevity and sustainability without optimal clinical