What Are the Benefits of Clinical Documentation Improvement (CDI)?

USING CDI TO POSITIVELY IMPACT CARE

Extensive EHR use and documentation pressure can lead clinicians to carve out a strict weekly routine.

"Certain times during the evenings or on the weekends, I make sure I spend a couple of hours prepping for the week to make sure my inbox is cleared out, all my refills are done, all my results are reviewed, patient charts are completed prior to their office visit, and ensuring I get my notes done within 24 to 48 hours," Neesha Patel, MD, Cooper University Healthcare, said in an interview with EHRIntelligence.

To mitigate workflow demands, Patel adopted and integrated an EHR scribe solution, called TrekIT, into the EHR.

EHR scribe tools aim to alleviate clinician burden and reduce the use of human scribes, which can be costly and have high turnover rates.

"I started using that to document and the workflow has been much simpler because I'm not planning my day around when I'm going to get my documentation done," Patel said. "Documentation is now a side note for me. The volume increased with COVID-19 for the number of patients we had to see, so I wasn't able to see all of my expected patients per day."

With the clinical workflow tool, Patel could treat her total volume of patients per day, which she said is not typical at a long-term care facility.

"I could see twice the daily volume," Patel said. "I'm not going to say it was a time-saver. It was more that it allowed me to invest my time elsewhere by having an effective way to document."

That meant Patel and her team could also invest time talking to nurses' aides and assistants to see if there are any subtle changes with the patient.

AMBIENT CLINICAL INTELLIGENCE: THE FUTURE OF CDI

While medical dictation software can help alleviate clinician burden, it is traditionally limited to the post-visit report, according to a review article published in Nature.

Ambient intelligence could help alleviate clinician burden related to a variety of EHR documentation tasks.

Ambient intelligence refers to physical spaces that are sensitive and responsive to the presence of humans, according to an article published by the National Center for Biotechnology Information (NCBI).

The technology hinges on data collected by sensors and processors imbedded into everyday objects and utilizes machine learning algorithms for data analytics.

For example, your Google Assistant and Amazon Alexa—devices that automatically respond to a person's voice—use ambient intelligence.

A study highlighted in the Nature review revealed that one healthcare provider's time spent on clinical documentation dropped from two hours to 15 minutes with the implementation of ambient intelligence through microphones attached to eyeglasses.

Implementing ambient intelligence could also lead to more accurate transcription than current EHR documentation aids such as medical scribes.

Another study highlighted in the Nature review revealed that a deep-learning model demonstrated a word-level transcription accuracy of 80 percent compared to medical scribes that average 76 percent transcription accuracy.

USING AMBIENT CLINICAL INTELLIGENCE CDI TO IMPROVE REVENUE CYCLE PROCESSES

While the EHR system has benefited the healthcare industry, it has also created other challenges for providers tied to the revenue cycle, according to Benjie Johnson, chief revenue officer at Michigan Medicine.

For example, Johnson has heard from providers about the number of clicks it takes for a provider to complete charge capture.

Accurate, quick reimbursement relies on not only charge capture, but also accurate documentation of hierarchical condition categories (HCCs) and other clinical information for payment systems using methods like diagnostic-related groups (DRGs) and value-based payment.

"Documentation is the key piece both for patient care and for revenue—that's where we really came up with, 'How do we make it easier to create documentation?' Because if it's easier to create documentation and edit documentation, then that will get us what we need from a revenue cycle perspective," Johnson told RevCycleIntelligence in a recent interview.

That line of thinking launched a CDI transformation project at Michigan Medicine and one that not even COVID-19 could stop.

"COVID hurt us financially and we had to implement an economic recovery plan that included FTE reduction," Johnson noted. "We paused major projects including facility and IT improvements. But in the midst of all that, leadership decided to move forward with the CDI project. That's how important it was."

Johnson and the project team looked towards ambient clinical intelligence tools to improve clinical documentation.

"It is definitely a futuristic goal that's not here just yet, but it seemed to make sense to partner with a technology vendor that has the same sort of roadmap, the same sort of vision, and has the capability of getting there," Johnson stated.

The medical center implemented a full portfolio of technology from 3M Health Information Systems to start on the path to ambient clinical documentation.

Michigan Medicine has implemented a coding and CDI workflow tool and front-end speech recognition.

Later, the medical center is planning to implement computer-assisted physician documentation (CAPD) and computer-assisted coding (CAC), as well as an HCC workflow.

"We have 3,500 providers with the full spectrum of clinicians who are computer facile and those who are not," Johnson said. "You have to take small steps in preparation for something like ambient technology."

"If they become comfortable with front-end speech and computer-assisted documentation, integrated with the EHR, it is our hope that the transition to ambient is not so daunting," he explained.

WHAT TYPE OF GUIDANCE ON CDI EXISTS FOR PROVIDERS?

AHIMA released two CDI toolkits in 2018 to ensure the entire patient record is documented properly. One focuses on outpatient documentation, while the other discusses denials management.

AHIMA HIM Practice Excellence Director Tammy Combs explained that documentation becomes more critical as providers continue to rely more and more on coded data.

"You know the old saying: if it's not documented, it didn't occur," Combs stated. "Now everything that's documented in the health record, is translated out into either an ICD-10 CM, ICD-10- PCS, or CPT code."

"These codes are how providers are recognized on the quality of care that they've provided," she continued. "This also impacts their reimbursement. [The code] tells the payer that's looking at these denied claims or researchers out there what diagnoses occurred. It helps determine the outcomes. If the documentation is not in place, then the accurate code cannot be assigned."

Provider education is key with CDI because there is truly a need for that higher level of specificity in the documentation process.

"It's important to provide education out to those provider groups so they understand what CDI is and why it's needed," Combs said. "Explain it's a resource for them to utilize, not a hindrance to them. It's a resource to ensure that they get credit for the work that they're doing by validating that documentation is of high quality."

As the digital health transformation progresses, healthcare organizations will continue to leverage CDI health IT to help ensure data quality for patient care, quality reporting, and other use cases.