Rapid Technology Advancements Impacting CDI, According to New White Paper from AHIMA and ACDIS
White paper finds CDI programs are evolving due to the advancement of healthcare technology
CHICAGO – December 7, 2021 – The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Integrity Specialists (ACDIS) released today a new white paper that examines how rapid advancement in healthcare 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 write, 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 write.
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,” said Tammy Combs, RN, MSN, CCS, CCDS, CDIP, CNE, a CDI practice director for AHIMA and one of the white paper’s co-authors. “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 said the white paper offered some noteworthy takeaways, including insight into how CDI programs are more prevalent in inpatient settings than outpatient settings. Combs said this is because outpatient encounters are typically shorter, leaving less time for CDI review. With outpatient providers increasingly using autogenerated queries, she said the white paper suggests organizations develop policies to perform quality reviews of these technology-driven queries.
Brian Murphy, ACDIS director and a co-author of the white paper, said 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 said.
AHIMA is a global nonprofit association of health information (HI) professionals. AHIMA represents professionals who work with health data for more than one billion patient visits each year. AHIMA’s mission of empowering people to impact health drives our members and credentialed HI professionals to ensure that health information is accurate, complete, and available to patients and providers. Our leaders work at the intersection of healthcare, technology, and business, and are found in data integrity and information privacy job functions worldwide. AHIMA.org.
The Association of Clinical Documentation Integrity Specialists (ACDIS) exists to serve as the premier healthcare community for CDI specialists, providing a medium for education, professional growth, program recognition, and networking. Learn more at www.acdis.org.
March 18, 2021
Looking for the underlying condition causing the encephalopathy is beneficial because it can help in the identification of the principal diagnosis.
March 10, 2021
A white paper written by a group of global HIM professionals and published by IFHIMA discusses how early planning, coupled with HIM leadership, is critical for countries transitioning to ICD-11 in an increasingly digital and data-oriented world.
January 27, 2021
When COVID-19 emerged in early 2020, new ICD-10-CM codes to identify this condition were not available. Subsequent ICD-10-CM codes and guidelines for reporting COVID-19 changed many times as the pandemic evolved throughout 2020.