A conundrum in clinical practice: Clinical documentation queries, more money, or more problems? A qualitative survey of hospitalists and surgeons in a safety-net academic medical center.

Abstract

As health systems increasingly rely on Clinical Documentation Integrity (CDI) programs to sustain revenue and quality performance, the physician experience of CDI remains insufficiently understood. In this qualitative survey of hospitalists and surgeons at a safety-net academic medical center, physicians acknowledged the importance of CDI for accurate billing and risk adjustment but frequently described queries as disruptive to workflow, emotionally taxing, and poorly aligned with clinical practice. Many respondents identified physician advisors as trusted system leaders who were perceived to improve communication and engagement. These findings highlight the importance of designing CDI processes that are timely, clinically relevant, and better integrated into physician workflows to support both documentation quality and physician well-being.