Updated on: November 6, 2018

Tracing the Evolution of Clinical Documentation Integrity

Original story posted on: November 5, 2018
CDI is the critical link to quality outcomes.

Any healthcare system’s overall performance relies heavily on a strong clinical documentation integrity (CDI) program, and therefore on the professionals at the heart of this discipline. From patient outcomes and mortality rates to financial reimbursements and quality score profiles, CDI programs affect the entire organization.

When hospitals and health systems make the transition to an advanced practice CDI program, they engage clinical, operational, and financial teams in improving healthcare-related activities, creating an optimal environment to realize improvements to patient outcomes, financial performance, and quality ratings.

In fact, it is recognized that both physician engagement and care quality improve when advanced practice CDI concepts are applied. Documentation becomes more accurate and features a more complete description of patient disease acuity. With this practice model, organizations realize significant increases in capture of severity of illness and risk of mortality, all because of CDI specialists (CDISs) enhancing physician engagement, which leads to direct impacts on quality of care and treatment decisions.

The first step, however, is to understand the advanced practice clinical documentation integrity competencies required to fill these essential roles.


Moving Beyond the Baseline: Expanded Skills, Expanding Role

Over the years, the CDIS role has evolved. At the outset, CDISs focused on correcting their hospital’s case mix index (CMI), improving reimbursement, and adding specificity to coding. And so the baseline, typical requirements for nurses and other candidates who were interested in becoming CDISs included having a minimum of five years of adult-care experience in medical/surgical environments, critical care, emergency room, and/or post-anesthesia care units.

But today, CDI is an integrated, interdisciplinary function that can affect millions of dollars in revenue, and more importantly, these programs have a direct impact on quality patient care. That is, CDISs provide information to all members of the care team, including those who treat patients. These changes have placed greater responsibilities and opportunities on the CDIS profession, putting these team members at the center of any care organization’s successful transition to value-based care.

There are several key characteristics that define a CDIS professional who can succeed and excel in an advanced functional role. Agility is key, and this must be combined with an ability to lead: to guide the organization in setting policies and procedures to prevent costly denials, to improve coding compliance, and to address shifting quality improvement needs. Additionally, senior-level clinical expertise and critical thinking skills must combine with strong project management skills and a demonstrated ability to communicate well with physicians and other healthcare providers regarding clinical encounters.

Finally, the right advanced-practice CDIS professionals will be proficient in harnessing the power of existing and emerging technologies to analyze and derive insights, solve problems, and establish new programs. Today’s computer-assisted solutions are increasingly supported by the convergence of artificial intelligence and clinical guidance. Together, these bring greater accuracy and specificity of clinical details at the point of care while also allowing CDISs to expand case review rates and focus on the cases with the greatest opportunities for improvement.


Elevating the Clinical Documentation Specialist Role to Advanced Practice

Healthcare professionals may be rethinking their competencies in light of healthcare reform, and CDISs are no exception. CDI programs encompass a myriad of people, processes, and technology that must work in harmony to ensure success. Transitioning from conventional CDI programs to advanced practice CDI demands collaboration beyond the traditional triad of the clinical CDI team, physicians, and professional coders through a convergence of technology, analytics, and interdisciplinary innovation to unlock enhanced quality patient outcomes and financial improvements. Similarly, this transition also requires a clear understanding of the skills, knowledge, abilities, and critical thinking capacity required of these professionals, who serve as the critical link to quality outcomes.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

Mel Tully MSN, CCDS, CDIP is the vice president of clinical services and education at Nuance Communications. She has played an important role in the development and expansion of Advanced Practice CDI™ for more than 18 years. She is recognized for her expertise, vision, and promotion of CDI. She is a national speaker and author for compliance, clinical documentation integrity, value-base purchasing, patient safety (PSI) and inpatient quality reporting (IQR) initiatives.

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