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CDI is metamorphosing into something unique and rewarding.

Clinical documentation integrity (CDI), formerly referred to as clinical documentation improvement, has been a strong passion of mine for the past 27 years, predating the recognition of CDI as a profession. I am always advocating for, and will continue to advocate for, transformational change in current CDI processes that do not lend themselves to true physician engagement as willing, active participants, which is necessary for an effective CDI program.  

There is a natural resistance to change within the profession, given the comfort level with the status quo. Change is not always easy, with some current forces in the industry content with present CDI processes. CDI associations and CDI consulting companies are happy with the current situation, since both are continuing to find it to be quite profitable. After all, why change if money is being made with software and consulting engagements?

Recently, I connected with a business development professional representing clinical documentation software solutions. We conversed over LinkedIn, looking at the firm’s website, and I was intrigued by the informational content to the point I requested a demonstration to learn firsthand the solutions’ functionality and capabilities.

During the demonstration, and after asking questions, seeking clarification, and reflecting, it became evident that this software’s capabilities and focus upon truly assisting physicians in capturing the formulation of the assessment and plan of care — reflecting their clinical judgement, medical decision-making, thought processes, and supportive clinical facts and clinical information — is the Holy Grail of accurate and complete physician documentation.

The software utilizes artificial intelligence to scour the record to ensure that no diagnosis is missed, helps physicians spend less time in the electronic health record (EHR), and improves the hospital’s bottom line while alleviating compliance and financial risks. No, this is not an advertisement for this physician documentation solution. So why am I providing you, the reader, with this information? Allow me to explain and outline below.

My contention has always been that at some point, artificial intelligence and other sophisticated IT applications adopted to the EHR would replace manual chart review by CDI specialists. There presently exists other documentation software solutions that purport to enhance CDI productivity by identifying and prioritizing cases with the highest propensity for documentation integrity and improvement, i.e., reimbursement improvement through additional CC/MCC capture.

In addition, there exist other software applications that “nudge” physicians through computer-assisted documentation, which prompts the physician to document “missed diagnoses” based upon available information in the chart. These offerings primarily focus upon diagnosis capture that impacts reimbursement or quality measures in some form or fashion. Coupling these software offerings with the CDI query process increases administrative burden of physicians by taking invaluable time away from direct patient care.

Now that there is a documentation solution powered by artificial intelligence-directed technology that automates clinical diagnoses with supporting documentation that populates into the chart, whereby the physician can either accept, amend, or decline the suggested diagnoses in real time, the question remains: how does this technology impact the CDI profession? 

Well, in participating with a client demo for this technology, that very question surfaced. There was unequivocal pushback from the CDI director, with reluctance to embrace a technology that not only enhances patient care, but also produces notes that are complete and evidence-backed, so they can be audited and easily read by compliance, payors, and physicians. My response to the CDI director pointed out that physicians want to provide high-quality care, spend less time documenting in the EHR, with less administrative burden, respond to fewer queries, and be able to assimilate all data available in the management of the patient to provide fully informed, patient-centered care. The real sticking point, obviously, was the potential displacement of the CDI staffers. This is where I was able to outline a vision of CDI as mentors, guides, and facilitators of complete and accurate documentation to physicians.

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