Improving the quality and efficiency of clinical documentation programs

What is at stake?

CDE programs have traditionally focused on improving the accuracy of inpatient provider documentation to support Medicare Severity Adjusted Diagnosis-Related Grouping (MS-DRG) assignment for:

• Appropriate reimbursement
• Patients’ severity of illness (SOI)
• Risk of mortality (ROM)
• Observed-to-expected (O/E) mortality rates

Accurate MS-DRG assignment correlates with reimbursement integrity, while SOI/ROM scores are linked to the quality status of a health care provider or facility. O/E mortality ratios compare the organization’s actual patient mortality rate against what was expected for other patients with the same diagnoses and procedures.

Advancing program maturity

While it’s correct for clinical documentation excellence programs to place emphasis on clinical documentation integrity, it’s equally significant that CDE operations be well-organized with strong leadership, executive support, and physician engagement. As the value of CDE programs increasingly impact organizational success, it’s vital that the mechanism for CDE operations be efficient and provide for continuous process improvement. At the same time, clinical documentation excellence programs should advance the quality, accuracy, and completeness of clinical documentation.

Current heath care trends

The completeness of clinical documentation is becoming more crucial. This is true not just in the hospital inpatient setting, but also across the continuum of practice as patient care services become more integrated, spanning all levels of intensity across all care settings.

Other key trends include:

• The expansion of CDE initiatives from inpatient hospital services to outpatient clinics, ambulatory surgery centers, medical group practices, and cardiac catheterization labs
• A shift in volume from inpatient to outpatient services
• The incorporation of physician practices, clinics, ambulatory services, etc., by accountable care organizations (ACOs) and the hospital industry as part of outpatient services to lower the cost of care
• The implementation of an outpatient CDE program with expansion of CDE influence to include hierarchical condition categories (HCCs) to improve the documentation of secondary diagnoses that drive risk-adjustment scores for quality of care

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) calls for “better care, smarter spending and healthier people” through emphasis on value over quantity. Data integrity is at the core of quality scores, value-based reimbursement, outpatient services, and denial management. Current health care trends are key drivers for achieving data integrity, making it essential for CDE programs to identify their present state of maturity and focus on initiatives to advance to the highest level of maturity.

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Our take

The maturity level of a clinical documentation excellence program determines its quality, efficiency, and effectiveness. Classification stages may include:

• “Beginning” practices
• “Developing” practices
• “Defined” practices
• “Advanced” practices
• “Leading” practices

Due to diversity in CDE models, staffing, and focus, CDE programs currently operate at different maturity levels with varying outcomes. These outcomes depend on the precise capture of principal diagnoses, procedures, and secondary diagnoses that, in combination, define the SOI and ROM data for each case. Additionally, CDE processes, policies, and procedures can vary from facility to facility, even within the same health system.

Multiple factors contribute to CDE program inefficiencies, including resource constraints, education and training of clinical documentation excellence and coding staff, technology platforms and support, and—most important—corporate culture. The following table describes the evolutionary stages of the Deloitte CDE program maturity levels. It also provides insight into operationalizing a cutting-edge, more refined CDE program that meets the current demand for more precise data.

Deloitte CDE maturity model

Each stage in the maturity model consists of four primary domains:

• Concurrent review
• Performance tracking
• Customer service
• Technology

Each domain has related processes that further define the expected degree of implementation by the organization. Based on the number of processes met within each domain, a measure of the program’s maturity level will be established. In order to realize the desired future state, an organization should consider conducting a fair assessment of its current level of maturity and work toward achieving the benchmarks that define a leading practice. Some initial questions to consider when assessing CDE program maturity for each domain may include:

• What are our present-day concurrent review processes, policies, and procedures? What is the degree of adherence?
• Are tracking and monitoring performed for the CDE program and individual(s)? How extensive is the tracking and monitoring?
• What type of collaboration exists among all stakeholders, including providers and executive leadership?
• How does existing technology currently restrict or enhance our program effectiveness?

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Forging ahead

The current shift to value-based care places greater implication on accurate health care data and reduction in compliance risks. CDE programs that are structured to be effective and efficient can provide the solutions needed to achieve accurate clinical documentation that contributes to precise health care data that’s required for value-based payment methodologies. Once an organization has pre-determined its maturity level, there are a number of steps that can be implemented to support future state goals and continuous improvement for the ultimate achievement of an advanced clinical documentation excellence program.

• Goal setting
• Gap analysis
• Stakeholder identification
• Technology assessment/improvement

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Related article

Leading CDE programs take into consideration the quality of people resources, the availability of important policies and procedures that guide departmental processes, and forums for continuous improvement, while incorporating emergent technologies to improve effectiveness and efficiency. They can also become platforms to promote the advancement of clinical documentation excellence into the outpatient arena. They’re an important consideration for further exploration as organizations attempt to meet demands for accurate clinical documentation to support value-based reimbursement methodologies in health care.

To learn more, download the full report, “A prescription for better data: Improving clinical documentation programs”, and visit our Revenue Cycle Management services page for health care providers.

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