CDI and Document Creation: Aligning Goals and Processes

August 13th, 2014 / By Jill Devrick

Last week I attended my first CDI Summit. As a specialist in the document creation process, I knew that I was going into the conference with a different perspective on healthcare documentation than most attendees, but I was hoping to see how the goals and processes of clinical documentation improvement (CDI) align with the goals and processes of documentation capture and quality assurance.

I was happy that all of the sessions I attended related in some way to how the documentation is being captured in health care, either through traditional dictation and transcription, speech recognition, templates, or direct data entry. On several occasions I heard the CDI mantra, “If it isn’t documented, it didn’t happen,” because the focus of CDI is on attaining accurate and timely documentation that reflects the scope of services provided to the patient.

In my experience, healthcare documentation specialists who are branching out from medical transcription into QA roles are asking the question, “If it is documented, is it correct?” This question goes beyond assessing the clinical scope, symptoms, diagnoses, etc., to encompass all aspects of data and documentation quality, so it makes sense for professionals on the creation end of the documentation cycle to work closely with the CDI professionals further along in the cycle to do what they can to influence quality and reliability. Indeed, AHIMA and AHDI have identified the opportunities in such a relationship, and next year they will be collaborating to hold the AHIMA CDI Summit and AHDI Healthcare Documentation Integrity Conference back-to-back at the same location from August 6-8, 2015.

Conference highlights for me included:

  • Hearing about CDI from the physician perspective and how physicians can capture more detailed content just by incorporating phrases such as “due to,” “manifested by,” and “indications include,” into their documentation. These tips will be helpful to individuals who train and/or support physicians in creating their documentation through various methods.
  • Discussions on the impact of natural language processing and computer-assisted coding on documentation quality, as well as where the technology is headed. Technologies such as these can be very effective and efficient, but only if the documentation being input and analyzed is of good quality.
  • A thorough overview of the concept of forms management in health care and how the lack of forms and data field management impacts reporting and analytics. Healthcare organizations have a daunting task, but a great opportunity, to take inventory of all paper and electronic capture methods so that they can identify areas of inefficiency, duplication of effort, common points where errors may be introduced, etc. Only when an organization maps out the reality of their data and documentation capture workflows across every department and process will they truly have a picture of what can be eliminated, revised, or added with the goal of streamlined, accurate, and practical processes that yield reliable data for reporting and analytics.
  • An update on information governance in health care and how HIM and HIT must work together to protect patients, providers, and their organizations from fraud, abuse, waste, errors, and other problems caused by inadequate information monitoring and management.
  • Recommendations for using time wisely to prepare for the October 1, 2015 ICD-10 implementation. Every organization should spend some time and resources on a gap analysis of the patient care documentation being generated in every department and specialty so that issues can be addressed appropriately. And, I might add, “overlap” analysis would be helpful too, to determine how areas of conflicting information (such as excessive copy/paste usage) might be resolved.

This year’s CDI Summit was full of ideas for how HIM, HIT, and all contributors to the documentation cycle can work together towards better, more efficient patient care documentation.

Jill Devrick, Product Solutions Advisor with 3M Health Information Systems, is current president of the Association for Healthcare Documentation Integrity (AHDI).