Documentation in the health care world is the fundamental communication method for clinicians in regard to their patients’ care.
It also serves multiple other purposes, including being the source of information that ranks physicians and hospitals on the quality and complexity of care delivered, which is increasingly publicly reported, as well as serving as an “invoice” for services rendered in order to support appropriate reimbursement.
A Vanderbilt University Medical Center initiative geared toward improving and sustaining clinical documentation and coding excellence (CDACE) began in late April. The work is being spearheaded by a project management office (PMO) that meets daily and is charged with creating a new system for supporting clinicians and coders.
“I want to thank members of the Medical Center’s leadership team and all other faculty and staff who have committed their time and talents to this important effort. Improving documentation and coding throughout our clinical enterprise is an essential step toward creating a more accurate reflection of acuity of the patients we treat and the outcomes we achieve,” said C. Wright Pinson, MBA, M.D., deputy vice chancellor for Health Affairs and CEO of the Vanderbilt Health System.
“First and foremost, documentation is about patient care,” said Titus Daniels, M.D., MPH, MMHC, associate professor of Medicine and executive director of the Vanderbilt Medical Group. Daniels is leading the CDACE effort along with Gaye Smith, MBA, who oversees the Center for Health Information Management.
“As we move forward in an era of health care change, we know that accuracy, completeness and specificity of the documentation are reviewed not only by our payors to come up with how they reimburse us for our work and for quality of care, but increasingly the public reviews these data also to judge us on the quality of the care we deliver,” he said. “It all begins with physicians’ documentation.”
Daniels said there are two aspects of the documentation process: documenting (or writing on a patient’s chart); and coding (translation of the information written by a physician into various administrative functions that ultimately reflect how sick Vanderbilt’s patients are).
David Raiford, M.D., associate vice chancellor for Health Affairs and chief of staff of the Vanderbilt Health System, and Cecelia Moore, MHA, CPA, associate vice chancellor for Finance at Vanderbilt University Medical Center, are the executive team leaders, with support from Daniels, Smith, Pinson, David Posch, Jerry Hickson, M.D., Ken Letkeman and Meg Rush, M.D.
To help get the endeavor off the ground, VUMC has engaged the services of Navigant, a consulting firm with expertise in clinical documentation excellence.
Raiford said the CDACE project represents a real opportunity for VUMC clinicians to be equipped with methods to document more concisely and precisely the outstanding care already provided to patients.
“The principal goal of this endeavor is to decrease the time devoted to creating effective and clear clinical documentation while enabling complete and accurate extraction of information from the record for other crucial functions,” he said.
“We’re putting a lot of focus on this to get a well-designed program that will be sustainable,” Daniels said. “After several months, the information obtained by the PMO will be transitioned into sustainable operational processes with ongoing clinician education and enhanced coding processes.”
