The recently concluded ACDIS conference in Chicago brought together a diverse group of professionals, including nurses and CDI specialists, all dedicated to enhancing clinical documentation improvement. The event was packed with informative sessions and networking opportunities, leaving attendees with valuable insights and key takeaways.
In this blog post, we will highlight some of the most significant lessons learned, incorporating perspectives from colleagues, and discuss how they can positively impact healthcare organizations.
People, Processes, and Technology
As cliche as it may sound, one key insight learned by interacting with attendees at the conference was the importance of the three pillars: People, Processes, and Technology.
This holistic approach recognizes that effective CDI requires a balance of skilled professionals, streamlined processes, and appropriate technological solutions. Emphasizing the interplay between these aspects is essential for achieving optimal clinical documentation outcomes.
The importance of streamlined processes for CDI success was also emphasized. Colleagues emphasized the necessity of standardizing workflows, establishing clear lines of communication, and fostering productive teamwork among various stakeholders, including doctors, coders, and CDI experts. The importance of clear procedures for timely documentation reviews, accurate code assignments, and efficient information flow was emphasized during conference discussions.
Is it clear that technology is crucial for a successful CDI program. Utilizing proper technological solutions can significantly improve the speed and accuracy of CDI processes. Tools like HITEKS CAPD360, which combines artificial intelligence and natural language processing, were mentioned as effective tools for locating documentation gaps, providing real-time suggestions, and facilitating CDI workflow optimization.
Automation of manual tasks, the reduction of documentation errors, and the ability for CDI professionals to concentrate on activities that add value are all made possible by technology.
Focus on Effectiveness and Efficiency
It was clear that many hospitals share a common goal: to find ways to be more effective and efficient in their CDI roles and the need to continually assess and improve their processes, leveraging best practices and industry standards.
Its critical for hospitals to regularly evaluate CDI performance metrics, such as query response rates, query acceptance rates, and documentation accuracy, to identify areas for improvement. By implementing data-driven approaches and monitoring key performance indicators, healthcare professionals can optimize their CDI efforts, leading to improved patient care outcomes and financial performance.
This is where HITEKS CAPD360 Insight™ shines. It eliminates the need to click and wait for results by enabling real-time provider-to-provider communication. All of this can be done quickly and easily from within your Epic EHR, without interfering with physician’s daily tasks. The CDI team maintains control at all times.
Our platform enables CDI specialists to identify documentation gaps in real-time and provide actionable recommendations to clinicians to improve documentation quality. Our embedded software for providers provides this ROI as they are responding to CAPD Queries in Epic’s Note Editor while typing:
- 25% CDI Resource Efficiency
- 1-month Implementation with no Additional Logins or Apps
- 3% Revenue Increase on Cases with CAPD Queries
- 50% Provider Efficiency in Responding
- 20% Reduced Denials due to Changed Documentation
- Up to 70% Concurrent Query Satisfaction before Discharge
Harnessing the Power of Technology
Technology as mentioned in multiple conversations is a vital component of CDI during the conference. While it remains challenging to some, there was a consensus that technology is indispensable in the CDI field. Colleagues recognized that embracing appropriate technological solutions can significantly streamline workflows, improve accuracy, and enhance productivity. The conference served as a platform to explore innovative tools and strategies, empowering attendees to leverage technology effectively in their CDI roles.
HITEKS understands the importance of data-driven decision making in driving CDI performance improvement. By leveraging comprehensive data analytics and reporting capabilities, HITEKS enables hospitals to evaluate CDI performance metrics accurately. This includes tracking query response rates, query acceptance rates, and documentation accuracy. With these insights, healthcare professionals can identify areas for improvement, implement targeted interventions, and continuously enhance their CDI processes.
By employing HITEKS solutions, hospitals can achieve better patient care outcomes and financial performance. Through increased documentation accuracy, hospitals can ensure the capture of all relevant diagnoses and conditions, leading to improved coding accuracy and appropriate reimbursement. The optimized CDI processes facilitated by HITEKS result in comprehensive and accurate medical documentation, minimizing coding errors and maximizing revenue integrity.
Compliance as a Priority
The importance of compliance was stressed as a key component for CDI programs. Emphasis remains on adherence to coding guidelines, regulations, and reimbursement models is crucial for accurate and compliant documentation. Maintaining compliance not only ensures appropriate reimbursement but also enhances data integrity, quality reporting, and overall revenue cycle management.
Compliant Query Practices* Followed by HITEKS
- All queries are memorialized
- Query titles and suggestions are not leading.
- Query formats follow the Guidelines.
- Provider queries include relevant clinical indicator(s).
- Undocumented diagnoses are not specifically suggested.
- Choices provided as part of the query reflect patient-specific conclusions.
- Prior information from other encounters is limited.
- Links are provided to access the clinical indicators.
- Impact on reimbursement, payment methodology, quality. metrics or severity of illness are not indicated in the query process
* Based on AHIMA/ACDIS Compliant Clinical Documentation Integrity Technology Standards, 2022
The ACDIS conference in Chicago provided valuable insights into clinical documentation improvement, incorporating perspectives from colleagues in the field. By embracing these perspectives and implementing appropriate strategies, healthcare organizations can enhance their CDI processes, improve patient care outcomes, and optimize financial performance.