Front-End CDI Should Be Core to Your Electronic Documentation Workflow

Clinical documentation improvement (CDI) has been the subject of some industry hand wringing lately. With Meaningful Use incentives in full swing and the transition to ICD-10 just around the corner, the adoption of electronic medical record (EMR) systems has kicked into overdrive. Many are wondering how CDI initiatives will fit into this increasingly digital workflow.

After all, as this line of thinking goes, the purpose of electronic documentation is to capture as much data as possible, as efficiently and consistently as possible, for every encounter. In a controlled, template-driven environment, how will CDI programs make an impact? In a workflow that prioritizes speed and efficiency, how will CDI specialists – much less physicians – find the time to implement improvements?

Without a doubt, electronic documentation has significantly changed the working life of CDI specialists. It starts with the tools CDI specialists have traditionally used – color-coded review forms, sticky notes and “hard charts” are now virtually obsolete. Now, review occurs in the EMR and can begin the moment a physician enters an electronic note. Queries can also be sent and tracked electronically. In an electronic workflow, CDI specialists don’t even need to be in the same city or country as the physicians to perform their duties.

But the migration from paper to electrons has not marginalized the value of CDI specialists. More than ever, an effective CDI program is integral to developing a successful electronic documentation workflow.

Electronic workflow tools enable an EMR system to serve as the hub of almost any data-driven activity a hospital performs. With instant access to any document in the EMR system, everything from documentation review and physician query to patient handoffs and quality reporting initiatives can be performed concurrently.

But an EMR is not a magic wand. Users across your health system rely on the same data from the same documentation at the same time. In such an interconnected environment, all the EMR system functionality in the world won’t overcome incomplete, inconsistent or inaccurate documentation. Capturing the right documentation at the point of care is absolutely critical to improving clinical productivity, patient outcomes and financial performance.

The Value of Front-End CDI

For many hospitals, code selection is the weakest link in their EMR’s documentation workflow. Without an integrated system to link documentation with billing, coding and review often takes place outside the EMR system. This gap may feel like a mere pothole today. But with the transition to ICD-10 less than two years away – and a codeset ten times larger than ICD-9 – this gap will soon become a canyon that swallows vast amounts of productivity and revenue.

Hospitals can span these gaps by implementing electronic physician documentation tools that enable physicians to select codes at the point of care. These documentation tools integrate with internal and external billing systems, as well as the EMR, to create a front-end computer-assisted coding solution.

With the right communication tools, a CDI program can fully integrate with the front end of an electronic documentation workflow to ensure accurate, comprehensive, high-quality data is captured at the point of care. By facilitating a real-time query and concurrent review environment, a front-end CDI program can drive substantial benefits across the health system:

• Achieve Broader Physician EMR Adoption - Physician participation is vital to the success of any EMR implementation. Unfortunately, many electronic documentation solutions simply make life too difficult for its most important users. Electronic physician documentation tools that deliver computer-assisted coding and CDI capabilities on the front end of the workflow help physicians capture information in the EMR as efficiently, accurately and intuitively as possible.

• Identify New Revenue Opportunities – With faster, more accurate communication across the care team, hospitals are able to complete charges faster and shorten billing cycles. By continuously improving the accuracy and completeness of the data captured at the point of care, a front-end CDI solution can help increase Case Mix Index and support additional reimbursement opportunities.

• Improve Documentation Quality at the Point of Care - A front-end CDI program creates a seamless loop of quality improvement that spans every documentation touchpoint. By identifying improvement opportunities across the workflow and implementing them directly at the point of care, front-end CDI helps hospitals achieve higher-quality documentation quickly and easily.

If your hospital is implementing an EMR or an electronic documentation platform, a front-end CDI program should be a core component of your strategy.