Experts say boosting documentation takes hospitalwide cooperation.
With recovery audit contractors cleared to resume limited medical record requests and ICD-10 once again on the horizon, many hospitals are casting a critical eye on their clinical documentation improvement (CDI) initiatives—and some are finding they have fallen short of expectations. In many cases, limited success rates can be traced to a lack of cross-departmental data transparency and adversarial relationships between participants that can disrupt workflows and hamper productivity.
“The biggest issue is that most CDI programs are developed with the physician as targets, not participants. CDI specialists are trained to fight the coders and fight the doctors,” says Robert S. Gold, MD, CEO of DCBA, a clinical documentation services company. “Too many people who are training CDI folks are mandating that they gather tons of useless information … that has nothing to do with what is wrong with the patient but rather has to do with keeping a paper trail. That slows down productivity massively.”