In CDS Snapshot, we're profiling CDSs from across Australia and ICD-10-AM countries. We'll get to hear how they got into the role, their triumphs, and challenges they've faced. CDSs contribute enormously to patient safety, quality of care, health service sustainability, and CDI as a whole, and we want them front and centre!
To launch CDS Snapshot in 2022, we're talking to Dr Joevin Vincent from sunny Queensland. Hear how his varied career and educational experiences, including being a international medical graduate, have contributed to his personal CDI approach.
Tell us about your current role.
As a member of a clinician led Clinical Documentation Specialist team at Gold Coast Health, I provide a support service for clinicians to ensure timely, accurate and complete clinical information is recorded in the medical record for clinical decision making, inter-disciplinary clinical communication and revenue assurance. My role involves acting as a bridge between clinical coders and clinicians to work towards the common goal of achieving integrity in recorded clinical information. The CDS service at Gold Coast provides support for best practice in clinical documentation through our ‘Nail Your Notes: Clinical Documentation for Excellence’ program that delivers the message – ‘Don’t just think…Ink the Link’. This program involves a multi-pronged approach of providing ‘real-time’ feedback to medical officers on active inpatient documentation by leveraging the functionalities of the ieMR (integrated electronic medical record), delivery of clinical specialty tailored education sessions, creation and distribution of simple and valuable self-reference guides, and ongoing engagement with clinicians to seek feedback that supports continuous quality improvement and promotes a gradual behavioural change towards adoption of best practices in clinical documentation. In addition, my role also involves maintaining a CDS Sharepoint site that is as a central access point for CDS resources, clinical form reviews, contributing to the Communicating for Safety committee, development of reports and above all, stakeholder relationship building and engagement that has been critical to our success at Gold Coast Health.
What is your career background, and how has that contributed to your ability to work as a CDS?
I am an International Medical Graduate from India who travelled to Australia in 2017 to pursue a Masters in Advanced Health Services Management. I believe that my training, experience and skills as a healthcare professional with a contemporary understanding of health information systems, information management, change management and project management strategies, combined with my knowledge of complex clinical processes provided me with an edge to manoeuvre through the complexities of healthcare funding, clinical coding standards and behavioural change management to provide evidence-based advice and collaborate with key stakeholders to design innovative, practical, and sustainable solutions. I recently received formal recognition as a Certified Health Informatician Australasia (CHIA) that has enabled to me contribute more towards my role as CDS by acquiring knowledge and skills across key domains of management science, information science and the core principles of health informatics. I firmly believe that clinicians are able to relate with me as a health professional as opposed to their interactions with a clinical coder or the finance department advising clinicians to document ‘key words’ for funding purposes.
What made you apply for a CDS role?
As a part of my internship with Gold Coast University Hospital’s Information and Data Management department, I completed the project ‘To Code or Not to Code’ that explored some of the complex issues around revenue leakage that the organisation was experiencing. A key deliverable of the project – The Survival Kit: ABF, Clinical Coding & DRGs, was created to provide some basic information to raise awareness on the significance of clinical information integrity. The establishment of a Clinical Documentation Specialist service in July 2019 coincided with the completion of my project and I applied for the role given its alignment with my skills and knowledge base that would be a fit-for-purpose. I was successful in my application and have utilised the CDS role as a launchpad for my career here in Australia.
What does your typical day look like?
A typical day for me since commencement has been fairly atypical. It has changed significantly over time since August 2019 and could involve anything from establishment of CDS processes and creation of resources to engagement with key stakeholders to communicate the significance of clinical documentation integrity and raise awareness. After the establishment of an e-Ink the Link process to provide real time feedback to medical officers, most of my day involves conducting reviews of active inpatient documentation and seeking clarification of ambiguous documentation. In addition to this, I conduct education sessions tailored to clinical speciality requirements and have also collaborated with our Medical Education Unit to provide medical officer orientation sessions. We have fortnightly catchups with our key non-clinical stakeholders – Clinical Coding Service and Health Information Managers to discuss progress and address potential areas for improvement.
What was the moment when CDI really “clicked” for you?
After we published the report for our pilot with the Stroke service - ‘Ink the Link: Using in Problem Oriented Plan’ which outlined the benefits of the use of a structured problem based management plan to support interdisciplinary clinical communication, the perceived value of clinical documentation integrity improved significantly. As a result of the clinical value that was demonstrated through interviews and feedback surveys, and the revenue recovery that the pilot had achieved, the evidence was speaking for itself. Unlike in the past, when we were reaching out to clinical services, we experienced an increased demand from clinical services to engage with us and implement a similar process in each of their services. The recognition and support that we received for our work after presenting at the CDIA conference in May 2021 also gave us confidence that we were heading in the right direction.
How would you describe your personal CDI philosophy?
Working in a tertiary centre, I realised that the solution may not be as simple as advising clinicians to ‘capture the clinical truth’. Different services have variations in their resourcing and clinical workflows that need to be taken into consideration. Different services also have different work cultures that the CDS may need to consider prior to providing a solution. I personally believe it is very important engage closely with key stakeholders and give them the opportunity to provide feedback that will enable us to provide advice that is tailored to the needs of the service. By working closely with the service, it also reduced the resistance to change as they are now aware of the reasons for the change and the potential benefits that it brings along.
What is the biggest challenge you have faced as a CDS?
With a constant turn-over of resident medical officers (who do most of the documentation), uptake of best practice in clinical documentation can be achieved with some effort; however, sustaining this practice is dependant on the culture of the team and support from leadership. I’m sure all members of the CDIA community recognise that CDI is not a destination, it is a journey. In this journey we have realised that this perceived challenge is actually an opportunity to influence cultural change by engaging with medical officers and leadership to drive this change towards the ‘tipping point’ and hopefully not following the timeline that Dr Ignaz Semmelwies was recognised for with his work around hand hygiene.
What is the most memorable “win” you’ve had?
Sustaining behavioural change is a challenge, particularly when the individual responsible for clinical documentation moves to a different clinical service every 6 to 10 weeks as a part of their clinical rotations. I consider it a win every time I see documentation by medical officers that I have trained in the past and have continued to demonstrate best practice in clinical documentation even after rotations to a different clinical service. On seeking feedback from these medical officers, I believe the main driver for them is not merely revenue optimisation, instead, it is the perceived clinical value that improved clinical documentation integrity can support safe patient care.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
‘But why!?!?’ I think would be a 20 year old me’s response to a 30 year old me. I use this point to engage with junior doctors and explain that I had to cross the Indian Ocean, re-locate to a different country, complete a post-graduation degree and a project on the value of clinical documentation to recognise that every progress note that I wrote had an impact on everything starting from the care that was provided to the patient to how the hospital received resources to provide that very care.
Favourite DRG?
This is a tricky one. It’s like asking a parent who their favourite child is. I’ve not got a favourite DRG but if you were to point a gun to my head and ask me the same question I’d pick B70: Stroke and other Cerebrovascular Disorders as this was the DRG that I initially worked closely with and provided the evidence that built a foundation for our ‘Nail Your Notes’ CDI program at Gold Coast Health.
Favourite additional diagnosis?
N17.9 Acute Kidney Failure, Unspecified. The number of times that I have seen treating teams managing this condition but not clearly documenting it has been astonishing. The likelihood of confirmation of this diagnosis through a clinician query has been highest.
What are you excited about in the future of your role?
As we exit the Information Age that was characterised by an economy primarily based on Information Technology and transition into an Age of Reckoning, I believe we are gradually realising that technology alone cannot support us if the information it is fed has missing elements. The potential of improved clinical documentation integrity to impact safe and quality patient care is yet to be realised across the healthcare industry. It excites me that I am working in this space that is continuously evolving and will continue to present challenges that we can tackle together as a CDIA community.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.