Identifying a Researchable Problem
The process of delivering care to patients is multifaceted and it involves a range of tasks but should be based on the patient preferences and current evidence (Melnyk, Gallagher‐Ford, Long, & Fineout‐Overholt, 2014). It is important for nurses who are carrying out research to have a look at relevant and current evidence in their respective area of study and analyze the available knowledge (Polit & Beck, 2012). The healthcare reform in the United States recently oversaw the adoption of the ICD-CM 10 which has increased the documentation requirements in electronic health record (EHR). In light of these new specifications, healthcare facilities need to make changes in their patient charts coding and physicians are required to understand the new specifications in clinical documentation (Nichols, 2014). The researcher seeks to develop a research question that will assess the impact of education provided by a Clinical Documentation Improvement Practitioner (CDIP) on the quality of clinical documentation. Further, the researcher will attempt to draw a comparison in Case Mix Index (CMI) and Patient Safety Indicators between a concurrent review and a retrospective review. A literature review of the current evidence will be completed followed by a synthesis of information related to the PICOT question. In this paper, the writer will to identify a researchable problem, provide a rationale and develop the PICOT question.
Clinical documentation has experienced widespread changes with the implementation of the ICD-10 diagnosis and procedure codes that were put in place by the Center for Medicare Services (CMS). Nichols (2014) explains that these new regulations have increased the documentation on physician’s progress notes to be reimbursed. The main purpose of this change is to enhance clinical documentation outcomes, improve the capacity to benchmark data between facilities across the United States, and ultimately enhance patient care. According to Hirsch, Leslie-Mazwi, Nicola, Oklu, Schoppe, Silva, & Manchikanti (2015), the reimbursement of care depends on how well the patient chart is documented and coded. The role of the CDIP will include monitoring the documentation and educating the physicians on the processes of documenting patient records so that it provides an accurate picture of the service intensity and the quality of care delivered to patients (Reyes, Greenbaum, Porto, & Russell, 2017).
Improper or inaccurate documentation by physicians will lead to lower reimbursement and a decline in the level of care provided to patients. For instance, a doctor who is in charge of documenting a diagnosis such as cardiovascular illness must specify the type of cardiovascular problem. The documentation within a chart should support a physician’s diagnosis. In addition, the physician is required to document any form of comorbidity that is impacting the length of stay. Hines and Yu, (2009) illustrate this by arguing that the difference between improper and proper documentation can be as much as four thousand dollars less per patient visit. Any inaccurate data will have an impact on the reporting on core measures since inadequate documentation results to poor quality measures reporting and reduced financial reimbursement.
It is important to come up with well-versed questions for research to ensure that the clinical question is answerable (Polit and Beck, 2012). A researcher can use qualitative questions which compares the meaning of an issue or concept or quantitative questions where data will be calculable. The PICOT acronym represents five factors that can be adopted in the formation of a research question. After a series of intensive and rewarding brainstorming sessions, the writer came up with the following questions to identify the PICOT question.
The identification of a research problem should be followed by a feasibility study of this problem. A number of aspects must be considered before commencing a study, even though they may not be needed for all research studies. These factors include; money, time, equipment, availability of participants, facilities, the ability of the researcher, and the cooperation of others (Polit & Beck, 2012). Following the introduction of the ICD-10 in 2015, facilities and providers are needed to make various changes to meet the requirement. To ensure the successful implementation of evidence-based change in the facility, it is essential to develop a research plan that would be implemented over a period of one year. The facility’s willingness to cooperate with the research plan is established and the plan will require minimal funding. As part of the study, the researcher will identify two units consisting of a study group and a control group. In one of the units, a CDIP will be assigned and they will educate physicians and offer support in matters related to documentation. The other unit will house control group and the physicians will not have a CDIP assigned to their unit. The participants consist of providers who are assigned to the two units, and the researcher must ensure that the units chosen for the study each uses a different crop of providers (Polit & Beck, 2012). In this study, the researcher is a clinical documentation improvement practitioner who has been certified by the American Health Information Management. The researcher will utilize the EHR that is in current at the facility for chart reviews, and prior to these they will have request for the facility’s permission to access the EHR.
The five variables represented by PICOT are (1) population, (2) intervention/issue, (3) comparison, (4) outcome, and (5) time. In relation to the PICOT question in this study the population that to be evaluated consists of hospital inpatients. The issue of inadequate documentation will result to deterioration in quality reporting and reimbursement, as well as a decline in the delivery of patient care. Vague, incomplete and illegible documentation inhibits reliable communication between nurses and physicians (Russo, 2012). A comparison of simultaneous reviews and retrospective reviews will be completed to confirm that the adoption of reviews during patient’s hospitalization will enhance patient care. The indicators of increased compound comorbidity, increased CMI, and PSI anticipated decline versus observed, will be used to determine if the improvement through education by a CDIP improve the outcomes. In relation to the variable of time, the gathered data will be assessed after one year to determine if the improvement has enhanced the outcomes.
The development of a PICOT question presents a model that can be used by researchers in the creation of a research plan for investigating an issue. The development of a question should clear and systematic to ensure that researchers and readers of the study findings understand the issue that was being discussed. The identification of a specific populace, intervention, comparisons, outcomes, and time period will help the researcher to ensure that they are successful in answering the question (Nieswiadomy, & Bailey, 2017). The PICOT question in this paper is: Education provided by a CDIP will enhance the outcomes of clinical documentation as illustrated by increased CMI and PSI in the event that a concurrent versus retroactive review is used.
The hierarchy of evidence consists of different levels of evidence with the top level providing the most reliable evidence. Polit and Beck (2012) posit that the main aim of keywords is help in the search for the best evidence research articles. The keywords that were used for this search include clinical documentation, clinical documentation improvement practitioner, patient outcomes, CMS core measures, patient safety indicator, case mix index, electronic health records, outcomes, concurrent review and retrospective review. When searched in the online databases, each of these keywords can map to headers and subject headings which can expand the scope when carrying out the article search. In addition, most of these words are part of the PICOT question and they constitute the concepts that the researcher will be exploring.
American Health Information Management Association. (n.d.). Certified documentation improvement practitioner (CDIP®). Retrieved from http://www.ahima.org/
Reyes, C., Greenbaum, A., Porto, C., & Russell, J. C. (2017). Implementation of a clinical documentation improvement curriculum improves quality metrics and hospital charges in an academic surgery department. Journal of the American College of Surgeons, 224(3), 301-309.
Hines, P. A., & Yu, K. M. (2009). The changing reimbursement landscape: Nurses’ role in quality and operational excellence. Nursing Economic$, 27, 7-14. Retrieved from https://www.nursingeconomics.net/
Hirsch, J. A., Leslie-Mazwi, T. M., Nicola, G. N., Oklu, R., Schoppe, K. A., Silva, E., & Manchikanti, L. (2015). The ICD-10 system: a gift that keeps on taking. Journal of neurointerventional surgery, 7(8), 619-622.
Melnyk, B. M., Gallagher‐Ford, L., Long, L. E., & Fineout‐Overholt, E. (2014). The establishment of evidence‐based practice competencies for practicing registered nurses and advanced practice nurses in real‐world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence‐Based Nursing, 11(1), 5-15.
Nichols, J. C. (2014, November 15). ICD-10 and clinical documentation [Video file]. Retrieved from http://www.medscape.org/
Nieswiadomy, R. M., & Bailey, C. (2017). Foundations of nursing research. Pearson.
Polit, D. F., & Beck, C. T. (2012). Nursing Research Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins.
Russo, R. (2012). Applying the principles of change management to documentation improvement. Retrieved from http://higherhealthcare.com/