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What’s Happening with HIM and Clinical Documentation Improvement (CDI) – HIM Scene

Posted on August 2, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

The world of HIM is constantly changing. It’s important for every HIM professional to stay on top of trends happening in the industry. With this in mind, I was excited to interview Steve Robinson, MS-HSM, PA-O, RN, SSBB, CDIP, who is the VP of Clinical Revenue Integrity at RecordsOne and ask him the following questions:

  • What’s the most exciting thing you see happening in the HIM world?
  • What’s the scariest thing people aren’t paying enough attention to in HIM?
  • What’s been the impact of CDI on healthcare and what will it be in the future?
  • How do you see the role of HIM changing in the next 5-10 years?
  • Make a big 20 years from now prediction for healthcare

Check out the full video interview we did with Steve Robinson to learn more about Steve’s perspectives on What’s Happening with HIM and CDI:

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Integrating CDI Efforts Across Inpatient and Outpatient – HIM Scene

Posted on October 19, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

One of the main topics HIM professionals have been discussing for a couple years is around CDI (Clinical Documentation Improvement). These programs have taken all sorts of shapes and sizes. Some are completely human driven. Others are largely tech driven, but most are a mix of the two. In fact, most CDI programs have gotten quite sophisticated and are really impacting the bottom line of healthcare organizations.

While most healthcare organizations realize that there are benefits to CDI, most of them have restricted these programs to the inpatient environment only. This was illustrated to me really well when I ran into a transcription vendor from India. It was his first time attending AHIMA and he was considering new areas of business including CDI. When we talked about CDI, his first comment was that he’d only ever seen CDI in hospitals, not in the ambulatory world.

While this is the case today, one HIM expert at AHIMA told me that one of the next big frontiers for CDI is going to be outpatient CDI. She went on to tell me that it’s fertile ground that could really benefit every healthcare organization. However, she also suggested that there shouldn’t be two CDI programs: 1 for inpatient and 1 for outpatient. Instead, CDI should be an integrated effort across inpatient and outpatient.

Clinical documentation improvement is only going to become more important in healthcare. Certainly, most CDI projects were started as a way to improve reimbursement. That’s a good goal and a benefit of a high quality CDI project. However, over time CDI is going to become even more important to an organization’s value based reimbursement efforts. In fact, if your clinical documentation isn’t accurate your reimbursement will really suffer. How can you keep a patient healthy if you’ve documented the wrong information for a patient?

How is your organization approaching CDI? Are you doing CDI in both inpatient and outpatient?

If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

Are We Outgrowing HIM Systems?

Posted on July 15, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin’s latest HIM Scene posts here.

We have changed and adapted to a rapid influx of electronic medical records and data over the last several years and it’s no surprise that some systems have struggled to keep the pace. Electronic medical records (EMRs) are in a state of constant revision to make sure patient care, clinical functionality, and data security measures are keeping up with our needs. It seems there are software application solutions or enhancements to almost every task we do in healthcare and these systems are also constantly evolving.

I don’t know of any healthcare application system or workflow that has remained static year over year and because of this, it is important for us to stay on top of vendors and keep an eye on current and future needs of HIM workflows. Clinical Documentation Improvement (CDI) is one of those areas that has been evolving since it first came on the scene and it is currently undergoing yet another face-lift. We realized there were many revenue opportunities hiding within inpatient clinical documentation and found that we could maximize reimbursement with a little detective work and physician education along with sophisticated software tools. Many are exploring the idea of CDI for outpatient levels of care. This means we will need software applications, interfaces, and expanded CDI workflows to extend these opportunities to outpatient documentation. Have you thought about what you will need from your vendors to adapt or upgrade current systems and how much will need to be budgeted for?

As we work to implement computer assisted coding (CAC) programs, we see opportunities to increase coder and CDI productivity and capture even more quality documentation by using discrete EMR data to our advantage. But are these CAC systems ready to be pushed to the limits to enter unchartered waters? I personally do not have a CAC success story to tell as of yet, but I am exploring the options and hoping that these systems have matured more than when we first explored them a few years ago.

That’s the beauty of technology in healthcare; if a product does not meet your needs, there may be other options already on the market or rapidly developing new technologies on the horizon. A vast amount of data may be held hostage in our systems if we do not maximize our EMRs and applications and set our standards high in a quest for knowledge. We can’t rely 100% on technology to dictate what we do which is why we need to be the visionaries and demand more from our systems in order to accomplish new and exciting things in HIM.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Can HIM Professionals Become Clinical Documentation Improvement Specialists?

Posted on April 21, 2016 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin’s latest HIM Scene posts here.

Most acute care hospitals have implemented a clinical documentation improvement (CDI) program to drive appropriate reimbursement and clarification of documentation. These roles typically live (and should live) within the HIM department. Clinical Documentation Specialists (CDS) work closely with the medical staff and coders to ensure proper documentation and must have an understanding of coding and reimbursement methodologies along with clinical knowledge.

Certain aspects of the CDI or CDS role require in-depth clinical knowledge and experience to read and understand what documentation is already in the chart and find what is missing. Some diagnoses may be hiding in ambiguous documentation and it is up to the CDS to gather consensus from the medical staff to clarify through front-end queries. There are many tools available to assist in this process by creating worklists and documentation suggestions based on diagnosis criteria and best practices. The focus of CDI is not entirely on reimbursement, although it is a nice reward to receive appropriate reimbursement for the treatment provided while obtaining compliant documentation for regulatory purposes.

Determining or changing the potential DRG prior to discharging a patient provides a secondary data source for many healthcare functions such as case management, the plan of care, decision support, and alternative payment models. For these reasons, a CDS must know the coding guidelines for selecting a principal diagnosis that will ultimately determine the DRG.

Inpatient coders also have the foundational skills to perform this role. Coders and HIM professionals are required to have advanced knowledge of anatomy and physiology, pharmacology, and clinical documentation. Therefore, to answer my original question “Can HIM professionals become Clinical Documentation Improvement Specialists?”, the answer is absolutely. But I will say that it depends on the organization as to whether nursing licensure and clinical experience is required in the job description.

Some organizations have mixed CDI teams consisting of coders and nurses while others may allow only nurses to qualify for this role. The impact of who performs the CDS role in the CDI program all lies in the understanding of the documentation, knowledge of coding guidelines, and detective work to remedy missing or conflicting documentation.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

How Is Your Hospital Approaching ICD-10?

Posted on December 12, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been writing quite a bit recently about ICD-10. You may enjoy this post I wrote about the real problem of ICD-10 being UNCERTAINTY. I’ve seen a lot of good reasons why we should go forward with ICD-10 and there’s no doubt that the move to ICD-10 does not come without a cost (training, implementation, system testing, etc). Although, not knowing if ICD-10 is coming or not is absolutely killer.

There are a lot of great ICD-10 resources out there to help you with your ICD-10 transition strategies. Although, I think most hospitals are wondering if they should prepare for ICD-10 or not. Those that were getting prepared last year got burned. Now they’re likely wondering if they’re going to get burned again. Those that weren’t prepared for ICD-10 last year were saved and they’re likely hoping to be saved again.

How is your hospital approaching ICD-10? Are you going forward with ICD-10 preparation using projects that are masked as Clinical Documentation Improvement (CDI) programs? Are you in wait and see mode? Are you going full bore in preparing, training, and testing for ICD-10?

I said that last one kind of ironically. I haven’t seen any organization that’s doing that right now which is really amazing. Last year at this time, I knew a bunch of organizations that were fully engage in preparations for ICD-10. This year, no such message. Last year at this time, many were calling for ICD-10 preparation. This year, people are afraid that they’re going to be “the boy who cried wolf.” There’s only so many times you can cry ICD-10 before people stop listening. We might be there already. It’s amazing the power of uncertainty.

As I said in my ICD-10 uncertainty post linked above:

My gut tells me that if ICD-10 isn’t delayed in the SGR Fix bill next year, then ICD-10 will probably go forward. You’ll notice that probably was the best I could say. Can anyone offer more certainty on the future of ICD-10? I don’t think they can and that’s the problem.

How Is Your Hospital Approaching ICD-10?

More CDI and EHR Optimization Discussion

Posted on December 5, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In response to the question I posted in yesterday’s blog post, “What’s the Difference Between CDI Programs and EHR Optimization?“, Richard Tomlinson, Founder and CEO of Nuclei Health Consultancy offered this response that I thought would help continue the discussion and be interesting for readers:

In answer to your excellent question, no. CDI and EHR optimization are not the same; in fact the two models are significantly different, as are their goals.

Without deep dives here, the root decision tree to choose CDI over optimization should be based upon analysis results to the issues and goals identified. What are the identified issues? And what are the identified and measurable goals.

I will share that workflow analysis is one significant differentiator between CDI and Optimization. If one of the goals mentioned above for example is to reduce time documenting , or, a shift of role assignment in portions of workflows to reduce cost or improve provider thruput, then optimization here may include the addition of technology. Sounds counterintuitive, nevertheless the business model of optimization is indeed different.

Reducing clicks in clin doc has been cited as optimization, but I am here to tell you that alone is not the case. I would tend to take that stand alone as CDI, although one can argue reducing clicks does not “improve” clinical documentation.

As an overall, I would tend to say optimization is holistic in its foundation to include analysis of workflows, content build specifications, ROI of additional technology/tools, education, with the cumulative impact compared to a set of defined clinical and business goals. CDI by contrast may support only a goal as simplistic as rearrangement or placement of data to achieve a specific benefit.

I look forward to hearing other people’s thoughts on this subject.

What’s the Difference Between CDI Programs and EHR Optimization?

Posted on December 4, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently heard someone describe their EHR optimization as a Clinical Documentation Improvement (CDI) project. It made me start to wonder if CDI and EHR optimization were quickly becoming the same thing.

While some CDI programs require EHR optimization, not all CDI programs require it. Some EHR optimization can improve clinical documentation, but not all of them. However, there is a decent overlap between the two efforts.

There are a lot of ways a CDI program can improve your clinical documentation. As we start to see full adoption of EHR software, most of the CDI programs are going to focus on the way the visit is documented in the EHR. While the EHR use might be to blame in many cases, the most important part of any CDI effort is the people that use that program. In fact, it’s often not even about how they use the program, but just the choices they make.

What has become very valuable is that EHR’s have made CDI programs much more efficient. They can run the program remotely. They can run reports that focus on common clinical documentation errors and focus their program on those specific errors. Technology can really help a CDI program to focus on the pieces of the chart that matter most.

EHR optimization on the other hand could have nothing to do with improving the clinical documentation. It very well may be that the clinical documentation is perfect. In an EHR optimization, you may only be looking at how to improve the physician workflow while maintaining the high level of clinical documentation.

EHR optimization is a powerful thing and not enough organizations are doing it. I get that they’re too distracted by meaningful use, but if we’re going to really benefit from EHR software we need more organizations focused on optimizing their EHR use.

It will be interesting to see how hospital leadership handles the governance of CDI and EHR optimization programs. They are both going to be very important going forward.