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The Clinical Documentation Conundrum

   February 01, 2017

There is also a sense that clinical documentation improvement is only one of many imperatives facing physicians. "Clinical documentation improvement for the sake of clinical care becomes one of the 20 things that the healthcare administration has to put in front of the physician," says Badlani.

Overall, U.S. healthcare is still at the beginning of these transitions, says Robert M. Wachter, MD, professor and chairman of the department of medicine at the University of California, San Francisco, and also author of the 2015 book The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, which delved deeply into clinical documentation issues in EHRs.

"My experience would tell me, that the places that do a big CDI initiative are largely thinking about their balance sheet," Wachter says. Instead, they should look for variations, determine costs of care, and ask why their care is more expensive than care elsewhere, he adds. "You need a higher level of documentation. You need to be more confident that these two patients really are requiring the same treatment, and why did it cost twice as much at this hospital we own than that hospital that we own."

"It's easy to copy yesterday's note and make it today's, and critics said you should just ban that. You shouldn't because there's maybe two-thirds of yesterday's note that is today's."

An example Wachter encountered during the writing of his book involved an epidemic Medicare saw four years ago of a rare African diagnosis of kwashiorkor, a severe form of malnutrition not common in the United States. "As soon as you see that, you know what's happened, that some CDI consultant came through and said, 'It looks like this patient has a low albumin, which is a blood protein level,' " Wachter says. "He says, 'Why don't you call that kwashiorkor, because it pays a hell of a lot better than 'malnourished' or 'wasted.' "

While CMS eventually got wise to this type of exaggeration, Wachter is concerned that as machine learning enters the toolbox of CDI specialists and management, such exaggerations could become yet another arms race between cash-starved healthcare systems. "As the money gets tighter, the premium on trying to figure out how can we, within the bounds of legality, get the doctor to write down the words that trigger the highest payment and provide the highest case-mix severity of illness—that's only going to grow," Wachter says. He also shares that he personally has an interest in tackling this, serving on the board of a company—Accuity Delivery Systems—that creates this kind of CDI technology. "It's just an arms race, but it is a race we all have to run," he says.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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