Critical Thinking in Health Information Management

In today’s fast-paced and interconnected world, the health information (HI) profession is becoming increasingly vital in the efficient functioning of healthcare systems. As technology revolutionizes how medical data is collected, processed, and disseminated, the need for skilled HI professionals who can navigate the vast sea of information with criticality and accuracy has never been more pronounced.  

In the era of information overload, the cornerstone of sound decision-making and improved patient outcomes lies in applying critical thinking. Critical thinkers are essential to almost all HI roles, especially those related to coding and clinical documentation integrity (CDI), as professionals strive to survive this new era of healthcare. 

By equipping these professionals with the necessary mindset, they can navigate the complexities of new-age data management while identifying potential pitfalls that could lead to detrimental consequences.  

Critical Thinking in Clinical Documentation Integrity (CDI) 

One area where critical thinking is particularly relevant is CDI and its application as a CDI Specialist (CDIS). The CDIS is a puzzle solver — a detective if you will — whose function is to be the bridge between the provider and the coder. A CDIS helps providers become better storytellers and communicate just how sick their patients truly are in words the coding professional can then translate accurately into codes.  

This is an actual patient situation that occurred where critical thinking was applied.  

Case study: 

• Patient was admitted for management of sepsis secondary to complicated urinary tract infection.  
• Per attending: Patient met sepsis criteria with white blood cell (WBC) count of 22 K, fever of 101.1, tachycardic to 100s; serum creatinine within normal limits. Urinalysis has white blood cells 131, leukocyte esterase is 500.  
• Urosepsis documented by three providers.  
• No quick Sequential Organ Failure Assessment (qSOFA) template used, no lactic acidosis (lactic acid 1.6) noted, or linked acute organ dysfunction present in charting. 
• Attending documented sepsis on hospital day one. 
• Patient was initially placed in observation status on hospital day one, admitted to inpatient status on hospital day three at 8 a.m., and discharged on hospital day three at 4 p.m. 

Would you automatically code sepsis based on this documentation? Based on previous experience, the CDIS knew the case could result in e an automatic denial if the sepsis was coded. The critical thinking process led to a clinical validation discussion with a physician advisor; through the CDI process the sepsis was ruled out and not coded.  

Tough Times 

American hospitals are facing a unique challenge. More than half were projected to have negative margins through 2022. Denials are on the increase. “Denials—when a claim is processed, but not paid—rose to 11 percent of all claims last year [2022], up nearly 8 percent from 2021. The 11 percent rate translates to 110,000 unpaid claims for an average-sized health system,” according to a recent report. 

CDIS manage various duties from developing compliant queries to provider communication, keeping up with ICD-10-CM/PCS, Current Procedural Terminology (CPT®), Hierarchical Condition Categories (HCC), Evaluation/Management (E/M) coding changes, Coding Clinic® updates, Medicare updates, National Coverage Determination/Local Coverage Determination updates, ; to name a few. To keep up with all of these responsibilities time management is essential along with effective communication skills good sense of humor, especially when the denials come raining down. 

According to a 2017 AHIMA study: 

“Although clinical (hospitals and non-hospitals, such as medical groups, alternative living facilities, and government community health centers) and non-clinical (IT (Information Technology) vendors, clinical research companies, managed care organization/health insurance companies and independent retail pharmacies) organizations align in many respects, some differences between clinical and non-clinical segments are evident: 

• The clinical segment places greater emphasis on operational needs and soft skills, e.g.: revenue cycle management and clinical documentation improvement, compliance, auditing, and fraud surveillance policy; social skills; and critical thinking. 
• Non-clinical executives, on the other hand, place greater emphasis on informatics, e.g., usability, research, natural language processing, precision medicine, and genetics.” 

With critical thinking, it is important for the CDIS to keep the focus on the patient. Documentation is the foundation of good patient care. The CDIS is responsible to validate that the documentation is correct and support accurate code assignment that represents the true clinical picture of the patient.  

According to the World Economic Forum’s report entitled “The Future of Jobs Report 2020” (see figure 27 B), critical thinking is listed as the number four top skill required in all areas by 2025. 

But how does one empower critical thinking? First, you must recognize that it can be taught. 

Authors and educators Jessica A. Chacon and Herb Janssen noted in 2021 that “Critical thinking is an active process that, when applied appropriately, allows each of us to evaluate our own activities and achievements. Critical thinking also allows an individual to make minor, mid-course corrections in thinking, instead of waiting until disastrous outcomes are unavoidable… Critical thinking skills are essential to the development of well-trained healthcare professionals. These skills are not ‘taught’ but must be ‘learned’ by the student.” 

The simplest way to foster critical thinking is through mentoring. According to expert Laurie Prescott: “If you are an experienced, critically thinking CDI professional, you can teach others. Instead of being critical of their performance, model the process. Ask the questions out loud so that observers can hear the wheels turning inside your head. Sit at the puzzle table with [the] new CDI specialist, explain what you’re doing while you sort through the pieces. Share your experience, be a leader in your profession. Share the skill of critical thinking, pass it on to others. It makes us all stronger.” 

Critical thinking is a skill that improves with use and time. An example of one way to initiate critical thinking as part of your team process can be as simple as these five steps, adapted from the book “Now You’re Thinking by Judy Chartrand, et al.: 

• Reflect and direct – you need to know what you need to accomplish 
• Differentiate facts from assumptions/opinions 
• Do I have all the information I need and is it relevant? 
• Can we achieve our goals with this information? 
• Let’s plan it out 

Critical Thinking and Medical Coding 

Critical thinking in coding requires recognizing medical documentation problems, prioritizing problem solving, gathering, organizing and presenting pertinent information, recognizing assumptions, and comprehending language with accuracy and clarity. 

Previously, before encoders and reports in health records created by speech recognition, coding staff were classified in most hospitals as clerical staff. Reports such as history and physicals, operative records, consultations, and discharge summaries were dictated by physicians and transcribed by transcriptionists who were hopefully trained to catch a physician misspeaking and correct it. (“Immediately prior to his demise, the patient underwent autopsy.” sic) 

The coders at the time were often instructed to “code what the physician said,” despite information which could be missing or inaccurate, as the coding position was not considered a clinical position — and physicians were routinely not questioned about their documentation.  

For example:  

The physician wrote: 

Principal/secondary diagnoses: 

• COPD 
• Hypertension 
• Diabetes without complications 
• Consultation with cardiovascular surgeon 

The physician ordered as take-home medications: 

• Lantus 
• BD Ultrafine Nano Pen Needles 
• Home Health 

It is important for coding professionals to review physician orders as well as discharge plans. They should review the health record for indications as to why the patient is referred to a cardiovascular surgeon, whether the patient is a Type 1 or Type 2 diabetic, and why the patient is on insulin. 

A major change in documentation came in the early 2000s, with the development of CDI programs. This was originally seen as the responsibility of registered nurses to work with physicians and clarify the physicians’ medical documentation. The problem, which quickly became obvious, is the difference between clinical thinking/documentation and the documentation requirements of the International Classification of Diseases. 

Challenges arose for clinicians as the “coding rules” were often inconsistent with clinical logic, which led to a “difference of opinion” between the CDI professional, clinicians and the coding professional.  

As time went on, however, each of these professionals began to see the other’s viewpoint, and CDI teams often became a blend of clinicians and coding professionals, which led to an efficient and coordinated process.  

The coding professional’s critical thinking must involve the physician’s documentation, both what is present in the health record and what could be missing. The coder needs to understand why the physician may order a particular diagnostic report and look for the follow-up in the record. The coder should also be able to look at medication orders for the physician logic and what the physician may be thinking.  

Critical thinking is an especially important skill in the coding professional’s toolkit as they are usually the last person to see the patient’s record. All of these requirements play into a comprehensive critical thought pattern for the coding and CDI professional to provide a full picture of the patient’s story.  

Leah Ainsworth, RHIT, CDIP, CCS, CCDS, is an AHIMA-approved CDI trainer and CDI manager with Springhill Medical Center. She has 30 years in health information management. 

Rani Stoddard, MBA, RN, CPHQ, RHIA, CCDS, CCS, CDIP, CDEO, CRC, is an AHIMA-approved CDI trainer and CDI Supervisor at Henry Mayo Newhall Hospital in Valencia, CA. She has been in clinical documentation integrity for more than nine years and in nursing for over 55 years. 

Adriana van der Graaf, MBA, RHIA, CHP, CCS, CDIP, is an AHIMA-approved ICD-10 CM/PCS Trainer. She has been in HIM for more than 35 years and is currently in private consulting.