From For the Record
AHIMA and the Association of Clinical Documentation Integrity Specialists (ACDIS) released a new white paper that examines how rapid advancement in health care technology is driving changes to the practice of clinical documentation integrity (CDI).
CDI is critical to the usability of medical data and ongoing efforts to improve patient care. New technologies, such as artificial intelligence and natural language processing, can streamline CDI initiatives, reduce administrative burden on providers, and achieve high-quality documentation. But the use of these tools requires a more sophisticated approach to assessing and incorporating them into the documentation workflow, the paper’s authors say.
The technology tools suggest query opportunities to the CDI professional based on “triggers” that are identified during an automated scan of the health record, such as documentation, vital signs, lab results, radiology findings, or medications. It’s essential, the authors wrote, that CDI professionals continue to look for opportunities in the record that were not suggested by the technology. “This is especially true when the opportunities are more complex and require critical analysis by the CDI professional to determine the big picture of what is happening during the admission and the clarification needed to reflect the true cause and effect of some conditions,” the authors wrote.
The paper also includes information on the variety of CDI-related technology solutions available, steps organizations can take to effectively evaluate new technology solutions, sample questions for vendor selection, and standards for achieving a compliant query practice.
“This white paper is a must-read for any CDI professional or healthcare leader,” says Tammy Combs, RN, MSN, CCS, CCDS, CDIP, CNE, a CDI practice director for AHIMA and one of the white paper’s coauthors. “Not only does it detail available technology solutions, this white paper shares strategies for assessing compliance with existing guidelines and details how CDI and coding departments can use novel technology solutions to improve CDI.”
Combs says the white paper offered some noteworthy takeaways, including insight into how CDI programs are more prevalent in inpatient settings than outpatient settings. Combs says this is because outpatient encounters are typically shorter, leaving less time for CDI review. With outpatient providers increasingly using autogenerated queries, she says the white paper suggests organizations develop policies to perform quality reviews of these technology-driven queries.
Brian Murphy, ACDIS director and a coauthor of the white paper, says it will help any CDI team improve their processes immediately.
“I’m pleased this practical resource offers base questions and guidance that can be used to help implement and support the adoption of technology solutions in CDI,” he says.