CDI is a foundation for quality measurement and reimbursement. It’s data that can be collected and analyzed in order to understand how accurately patients are being diagnosed and corresponding documentation to support their diagnoses, and whether or not they’re receiving the right kind of care.

As a medical provider, you have a responsibility to ensure that your patients receive the best care possible. You also have a responsibility to ensure that your documentation is complete and accurate.

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding and quality metrics cannot be achieved.

Data is a valuable resource, and it’s only going to become more valuable as time goes on. However, collecting data from a wide range of sources can be difficult and time-consuming, which means that businesses have to spend a lot of time manually querying their providers for answers to questions.

But what if you could automate some of this? What if you could make use of the data in your database to provide you with proactive answers before you even had to ask?

The first step in the Proactive Approach to CDI is developing standardized definitions of clinical language with providers and coders that enhance the clinical practice of medicine. Next, it’s important to partner with other clinicians (e.g., wound care, antibiotic stewardship, respiratory therapy, preprocedural assessments, care management, quality, and sepsis coordinators) toward standardizing clinical language and facilitating its proper entry into the EHR.

Collaboration with executive leadership, managers, utilization review, quality, and case management in meeting common goals is also necessary. This collaboration should be supported by developing and integrating EHR documentation infrastructure (e.g., templates), as well as technology (e.g., artificial intelligence), which will help automate queries and improve real-time physician notifications using advanced data analysis.

Finally, it’s important to automate the analysis of clinical data that identifies CDI risks so that you can focus on improvement activities and refine your approach in a timely manner.  Delays in CDI mean delayed revenue cycle and downstream bottlenecks in appropriate claims coding and quality metrics reporting.

This approach includes developing collaborative relationships between clinicians and coders, as well as establishing an EHR infrastructure that facilitates proper entry of clinical language. It also includes developing templates and “smart phrases” to make documentation easier, as well as using artificial intelligence and other technologies to analyze data and identify areas of risk and opportunity.

In the near future there will also be Natural Language Generation whereby the computer automates the full creation of a clinical note from existing data, and the clinician reviews the note instead of spending the time to construct it from scratch or a template. 

Epic’s May 2022 release  includes a workflow feature that provides feedback within seconds PRIOR to saving/pending or signing.

The new feature, On-demand Analyze Note functionality is designed to improve clinical note accuracy and timeliness without the need for additional software or retrospective queries to the physician, allowing them to learn from their own note-writing and improve compliance with ICD-10 and clinical validation.

The On-demand Analyze Note available in Epic’s May 2022 release will be replaced in Epic’s November 2022 release with a fully automated ( Embedded In-Progress Note Editor) feature where after a few seconds of a clinician not typing, they will receive the analysis of their note with an indication presented at the bottom of the Note, allowing them to make edits as needed before it is saved/signed.

As CDI continues to evolve, the future looks bright.  These new technologies are meant to simply reduce the query burden on physicians by providing them with an easier and quicker way to receive and respond to queries within workflow.  Retrospective, manual, reactive queries will always be a component of the revenue cycle process, so there’s no replacing that activity.  Rather, the reduction of those reactive queries and the increase of proactive ones will be the trend until a harmonious balance is reached. 

More queries that the manual CDI process offers may be necessary in the beginning to ensure that physicians are reminded of the need to correct and bolster their documentation, but the goal is to reduce what they have to do retrospectively which creates bottlenecks in responding and reduces the revenue cycle and frustrates physicians.

The capabilities are here and the technology is continuing to improve. The best practices, as identified in this article, can go a long way in enabling success as you work towards increasing quality and revenue while decreasing your administrative burden.