The Importance of Clinical Documentation Improvement

The importance of Clinical Documentation Improvement (CDI) is well understood. However, set against new outcomes and performance benchmarks, evolving payment/reimbursement mechanisms (including support of population health management strategies) CDI takes on a more time critical role.   CIO’s and CMIO’s recently participated in a series of focus groups at the CHIME Fall Forum to discuss and relate their perspectives of CDI.   CDI is in place in many enterprises varying significantly in maturity and governance, yet all validated its increasing importance to the economic viability of organizations.

Drivers and Market Dynamics

CDI is well underway in healthcare organizations. The initial drivers have been financially focused, and as understanding of new payment models and population health scenarios emerge, an emphasis on quality/outcomes performance will emerge.

CDI for the most part does not reside under the CIO’s domain, most often it may be within the purview of the CFO, COO or in some cases legal. CIO’s are filling multiple roles – such as technical to ensure IT infrastructure (applications and hardware) are in place; as well as administrative as part of the CDI governance structure. CDI initiatives represent cross organizational value in support of operational, financial and clinical performance, and increasingly play a strategic role in an organizations competitive positioning.

Challenges and Opportunities

Although several significant internal challenges are being faced by organizations, such as establishing a governance and leadership model that crosses enterprise silos, lack of EMR functionality and integration, as well as clinical resources, the roadmap is clear that organizational change in support of CDI is critical.

The disciplines and results gained in hospitals based on CDI efforts may also prove valuable in the ambulatory environment as proposed restructuring of the Sustainable Growth Rate (SGR) formula are considered. The proposal would permanently repeal the SGR update mechanism, with greater focus on value (outcomes) over volume, and encourage participation in alternative payment models (APM) such as value based purchasing.

Implications and Imperatives

Successful deployment and implementation of CDI initiatives will rely on the integration of combined internal and external clinical resources; coordination of EMR vendor support along with documentation improvement applications and performance improvement consulting resources.  Successful CDI programs and leadership in the future will provide the roadmap, align governance, and enable IT infrastructure in order to meet regulatory mandates, support revenue optimization, and position their organizations to operate in the emerging performance based market environment.