Clinical documentation improvement (CDI) has become more important than ever, but poses “unique challenges” with the proliferation of electronic health records, according to a new article in the Journal of AHIMA.
EHR use can create inaccurate or insufficient documentation, due to note bloat with copy and paste and other issues. The accuracy of data is also complicated by the fact that some providers still use paper records or a combination of paper and EHRs.
As a result, many hospitals have created CDI programs to design new query processes so that the data in EHRs are more structured and to reduce query response time. This becomes more important as the industry moves to health reform and ICD-10. CDI specialists can also customize and standardize query templates, for instance to focus on pediatric content for a children’s hospital, the article's authors write. Entities that also use natural language processing can auto-generate queries for specificity to free up CDI professionals to look at what’s not said in the record that might be needed, such as the type of equipment used in a procedure.
It also helps to use query templates that are succinct and clinically orientated in order to facilitate clinician response to the query, and to consider the workflow involved. For example, some hospital departments may prefer that the query be addressed to the entire team, not to an individual, according to the article.
“[C]ommunication--whether over the Internet or over a drink--is the cornerstone of any relationship. This is also true with CDI. Whether remote or in-person, on paper or digital, queries will get answered only after it is ensured the message can be clearly interpreted by both parties--and the mutual motivation for corresponding is in place. And that, like anything, involves putting in the proper work and effort to build a communication system that works," the authors write.
To learn more:
- here’s the article