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Clinical Documentation Improvement for Outpatient Care: Design and Implementation Editor’s Note:

This Practice Brief is based on an excerpt from the AHIMA Press publication Clinical Documentation Improvement for Outpatient Care: Design and Implementation

by Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CPC.




THE AHIMA FOUNDATION has established competencies for health information management (HIM) professionals, including clinical documentation improvement (CDI) practice, as part of an effort to establish new curricula and teaching methods for college and university HIM programs throughout the United States.

For example, as HIM programs become increasingly sophisticated, educators can use “unfolding” case studies, which can foster “a learner-centered classroom, where the student is actively engaged in the learning process. In this format, information is presented in several stages. At each stage, the student engages in critical thinking and problem solving.”


Critical Thinking Defined

Critical thinking involves the following key tasks:

Validating information

Identifying exceptions

Analyzing trends

Considering what is not there

Thinking “outside the box”

Being creative


To accomplish these tasks, the critical thinker must be open to new information, alternative explanations, and unbiased consideration of what one presumes to be true about a given situation or problem before a conclusion is reached. “The primary difference between thinking and thinking critically is the added dynamic of having a purpose and control for the thought process.”

Thinking critically requires more than criticism of the current state of affairs. Rather than a negative activity, it is a positive process developed to identify effective solutions to complex issues. Potential steps to critically consider a positive solution to a complex problem include:

Gather and analyze information.

Develop a set of assumptions as a basis for the thought process.

Use scientific methods to develop conclusions.

Discern the validity of knowledge sources using questions and judgment.

Apply a creative thought process to develop possible solutions.

Analyze the feasibility, advantages, and disadvantages of possible solutions. Determine necessary action.

Positively communicate a proposal to stakeholders.

Implement best-practice solutions.

The use of critical thinking allows for confidence through success, independent action, collaboration when needed, and effective, creative solutions that improve job satisfaction.


Why Is Critical Thinking Necessary in Healthcare?


Critical thinking skills are necessary in today’s healthcare environment because of the complexity of the industry. Healthcare professionals must apply analytical skills to make complex decisions for high-quality patient care delivery. The intricacies of the electronic health record (EHR) and associated interoperability issues have added a layer of complexity for providers and healthcare workers. The internet has exponentially increased the amount of information on any subject, resulting in the specialization and subspecialization of today’s providers, clinicians, and nonclinicians. Historically, there may have been one professional performing a combination of functions such as HIM management, quality assurance, utilization review, and CDI activities; today, however, each of these functions is typically performed by a specialist in that area. Critical thinking skills are an area of focus for many healthcare managers as they encourage their staff to think through problem solving at a higher level.


Traditionally, clinical documentation specialists (CDSs) may have been selected for CDI positions based on their clinical expertise. Today’s CDI team members must be competent in many other areas. CDI managers are calling for more highly skilled thought leaders who not only learn their specific area of expertise but also keep abreast of current research in interrelated areas in order to tie together a bigger picture of issues they face on a daily basis. The outpatient CDS should therefore learn about the organizational goals and objectives, budget issues, staffing constraints, key performance indicators, and strategic plans that affect the outpatient CDI areas during the day-to-day problem-solving process. Critical thinking skills allow the CDS to become a transformational leader who can do the following:


Challenge preliminary solutions.


Example: The outpatient CDS has been the key CDI staff member on the new outpatient CDI pilot clinic implementation. They understand that the hospital has been closely monitoring budgets because of a downturn in revenue related to the increase in risk-based payer plans. The initial plan for the CDI program rollout to additional clinics involved adding one outpatient CDS to each site. After working on the initial clinic Clinical Documentation Improvement for Outpatient Care: Design and Implementation Editor’s Note: This Practice Brief is based on an excerpt from the AHIMA Press publication Clinical Documentation Improvement for Outpatient Care:The outpatient CDS streamlines some of the workflows to decrease time requirements and allow for remote CDSs to cover multiple clinics. The outpatient CDS presents this new process to the CDI taskforce. The CDI manager compliments the outpatient CDS for their critical thinking skills and for saving the health system money.


Expand root cause analysis.

Example: The outpatient CDS reviews the response and agreement rates for her clinics on a weekly basis. She notices that the response and agreement rates for Dr. Smith are much lower than those for the other providers in the internal medicine clinic. After collaboratively discussing the issue with Dr. Smith, the CDS learns that he travels to several of the outlying clinics because his subspecialty is endocrinology. Because of his travel schedule, he misses out on the onsite benefit of having a nonprovider clinician help during the query process by notifying the physician of any outstanding queries for the case just before the patient encounter. To ensure that Dr. Smith also gets previsit notification of queries, the outpatient CDS and Dr. Smith agree to a revised workflow that would include the use of an EHR alert on the patient’s record. This alert will allow Dr. Smith to see the query prior to the patient encounter or as he is opening the case while in the patient room. The new process results in a significant increase in query responses and agreements by Dr. Smith.


Use critical thinking to identify more streamlined solutions and workflows.


Example: The outpatient CDS notices that the MIPS measure that includes a diabetic eye exam is not being captured by the primary care providers. Provider education has been conducted on several occasions, but the capture rate has not improved. During a recent meeting with the new EHR vendor, the outpatient CDS learns of enhancements to the system that include in-line documentation prompts that could be used to query providers about the need for a diabetic eye exam on diabetic patients. The outpatient CDS creates the wording for the prompt and the exact point in the documentation process where the prompt should occur. She then sets up a meeting with the CDI manager and EHR vendor to discuss the possibility of including this prompt during the new system implementation. The outpatient CDS should always be on the lookout for opportunities to use critical thinking skills to improve workflow, provider-communication process, and stakeholder collaboration. The issue at hand is not always obvious after a high-level investigation. A more in-depth root cause analysis, although more time-consuming, may lead to more cost-effective processes, improved key performance indicators (KPIs), and better collaboration among stakeholders.


Critical Thinking and the Learning Process

To improve one’s critical thinking skills, one must focus on learning and be open to new ways of doing things. Research has shown that traditional learning occurs when a student reads a textbook and listens to lectures focused on the instructor rather than the student. This is an example of passive learning. Also, in passive learning, the student is required to read specific chapters and research articles in preparation for a quiz. In contrast, using the assigned materials as the starting point for a research project is an active form of learning that helps solidify the information studied. Active learning methods are more successful than passive methods. Learning environments in all disciplines, including medical education, are moving toward active learning models.7 Bloom’s taxonomy categorizes levels of learning from low to high. The active learning model aims to move learning from recall, understanding, and application—forms of lower-order thinking—to analysis, evaluation, and creation—higher-order thinking. The typical CDI trainee may begin practicing at the knowledge level, learning and recalling the basic concepts of CDI as they are introduced by managers and during training. The trainee may enter the job from a college or university program or from another healthcare job within the current facility. Understanding, the next step, occurs as the CDI trainee begins the case review process while being shadowed by the trainer. The CDI trainee moves to the application level as he or she applies the knowledge of CDI and the case review process to identify opportunities for queries based on clinical indicators, knowledge, or medical necessity guidelines and quality measures.


The analysis step occurs when the CDI trainee reviews metrics on query, response, and agreement rates to determine gaps for specific providers. Evaluation is demonstrated when the CDI trainee reviews the clinical documentation process for providers with response and agreement gaps. During this root cause analysis, the CDI trainee determines the reason why the provider has not responded or agreed at the expected rate. During the evaluation stage, the CDI trainee must collaborate with the providers and staff to develop a new workflow that corrects the problem. The highest level of thinking, which occurs during the creation state, takes place when the CDI practitioner, who is no longer a trainee, has become a subject matter expert and presents findings and solutions to the CDI manager and taskforce. These solutions typically can be used to assist other practitioners to improve KPI metrics, provider adoption, and provider collaboration.


Reference: Journal of AHIMA


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