As hospitals and clinicians, we are facing increased scrutiny of the care we provide to our patients. There is increased demand for more transparency of our outcomes and a need for increased efficiency of the care we provide in the setting of already significant documentation burden and its known impact on provider burnout.
Clinical documentation integrity (CDI) is an instrumental department which supports complete and accurate documentation, serves as a bridge between physicians and hospital coders such that hospital reimbursement is appropriate and quality metrics are attributed appropriately to the hospital, service lines, and individual providers. Complete and accurate documentation also leads to the submission of coded/claims-based data reflecting provider true intent and to clinically valid data for research and patient centric purposes. For this reason, the physician adviser role as a liaison between physicians and CDI and coding, in addition to utilization management and case management, has become more commonplace. The physician adviser role has been a mainstay of CDI programs across the United States since as early as 2012.
At the University of Colorado Health (UCHealth), the physician adviser role first began in 2015 at our major academic medical center, the University of Colorado Hospital (UCH). That physician adviser, after the additional physician adviser FTE at UCH, having established relationships with physicians across service lines, began to focus on CDI-related education and communication as it pertained to inpatient documentation.
At our institution we have approximately 500 advance practice providers (APPs). Approximately two-thirds of the APPs care for inpatients on a myriad of different service lines and, along with physician learners from interns to fellows, complete the bulk of the documentation in the electronic health record.
In early 2018, the UCHealth office of advanced practice collaborated with CDI in its mission to optimize documentation with the aim to have a positive impact on reimbursement and quality metrics while highlighting APP value. In the relatively early stages of the collaboration it became evident that an APP adviser could be an innovative and effective approach in engaging our many APPs with CDI as faculty members who are generally service line based and, as such, invested in hospital and service line outcomes.
A business case for a new position of APP adviser for CDI was formulated based on not only the number of APP faculty and learners at our institution, but also on the premise that the level of consistency APPs provide would increase reliability in the adoption and adaptation of documentation practices as medicine and coding rules evolve. In addition, APP documentation can stand alone without physician attestation or signature, unlike physicians in training, further making them ideally suited collaborators. The position was approved by hospital leadership and the first APP adviser for CDI in the country (of whom we are aware) was hired at UCH in July 2019.
A dedicated APP CDI adviser facilitates the success of a CDI/APP collaboration through a better understanding of APP engagement needs largely by creating new and/or fostering existing relationships between the APP adviser and the APPs for each service line. The APP CDI adviser identifies the needs of the team in order to maximally enhance their documentation while illustrating how the work/collaboration can positively contribute to APP clinical and/or academic goals. The APP CDI adviser possesses a deeper knowledge of APP clinical work flow and how that work flow might be impacting the documentation. He or she utilizes information gathered from the APP team to create more efficient note templates, provide lunch and learns with different service line APPs, and offering 1:1 drop-in documentation support, allowing for more feedback flexibility in context of their clinical work flow.
This real time input may be received more positively and be perceived as less intimidating in the peer-to-peer context. The APP adviser also attends various educational forums to which the physician advisers may not have access. For example, the APP adviser attends monthly APP orientation to meet new APPs for the institution, attends APP council, is a member of the APP steering committee, and provides documentation tips for the APP monthly newsletter.
At this point we are in the process of collecting pre- and post data to illustrate the benefit of a CDI APP adviser (and the CDI APP collaboration as a whole) through metrics such as CC/MCC capture rate, case mix index, and mortality and length of stay as influenced by the level of complexity in documentation. We hope to add APPs as advisers across the UCHealth system over time and to continue to highlight and publish the experience and outcomes related to this innovative role as it evolves such that other institutions across the country will consider this type of collaboration.
Dr. Anoff is associate professor of clinical practice in the division of hospital medicine and medical director of clinical documentation integrity at University of Colorado Health, Denver. Ms. Brill is senior instructor in the department of neurosurgery and APP adviser of clinical documentation integrity at UCHealth Denver Metro.