Reflecting on the past year in the realm of Clinical Documentation Improvement (CDI), particularly in countries using ICD-10-AM and AR-DRGs, it's evident that the field has experienced substantial growth and transformation, especially following 3 years of turbulence thanks to the impact of Covid-19.
The period over the past 12 months has been marked by developing conferences and events, an increase in CDI roles, evolving practices, and the emergence of technology, all of which have contributed to the advancement of CDI. Before we head into 2024, it is important to cast our minds back to what we have experienced and achieved over the past year. Here are some of my takeaways:
Growth in CDI/CDS Positions: There's been a noticeable increase in the number of CDI roles. Whereas in previous years advertisements popped up every few weeks, it is now not uncommon to find half a dozen CDI positions advertised at any given time, and that is just in Australia! In the Kingdom of Saudi Arabia, the Central Board for Accreditation of Healthcare Institutions (CBAHI) standards state that every hospital must have one or more staff members who are credentialed in clinical documentation improvement through formal training, meaning the number of roles is rapidly accelerating.
There is no indication that this growth will diminish any time soon, with the growing recognition at the hospital executive level of the importance of skilled CDI professionals.
Executive Buy-In: Hospitals executives continue to develop their understanding of the true impact of CDI, rather than purely a blinkered approach to revenue maximisation. Hospital programs are beginning to focus on the quality aspects of CDI including hospital acquired complications (HACs), related readmissions, adverse effects, clinical incidence, and system risks such as copy and pasting in EMRs. As we know, the success of any project filters from the top down. If hospital executives can not only fund, but support, advocate and support CDI in their organisations, I suspect we will see even greater acceleration in CDI.
Evolving Role of the CDS: With this growth and momentum comes the development and expansion of the role of Clinical Documentation Specialists. Concurrent reviews are now becoming the preferred model for patient reviews, and rightfully so. This shift is geared towards improving documentation quality and fostering a culture of documentation integrity that will ultimately improve patient care and safety, not just solely focusing on the dollars.
CDI Events & Forums: The third CDI conference held on the Gold Coast in September was a major highlight, drawing participants from Australia, New Zealand, and Saudi Arabia. It served as a vital forum for sharing experiences and knowledge, highlighting the need for such collaborative platforms in the CDI community. We also saw CDI centric presentations at the joint IFHIMA/HIMAA congress, indicating a broad and deeper understanding of CDI's role across a range of invested stakeholders. The reestablishment of the HIMAA CDI Community of Practice and the ongoing efforts of the HIMAA CDI Working Group underscore a commitment to collective learning and professional growth within the CDI field.
Rise in Certified CDSs: There's an increasing trend of CDI professionals seeking certification and advanced training, indicative of a maturing field with a focus on continuous improvement and professional development.
Technology's Emerging Role: What is starting to emerge, and what we are still seeking to fully understand, is the role of technology and artificial intelligence in clinical documentation improvement. Workflow tools that aid the CDS in episode prioritisation, data capture and reporting are great tools to improve efficiency and report on performance and outcomes. Unlike in the USA, where EMRs dominate the hospital record type, many hospitals in ICD-10-AM countries are still operating with a paper or hybrid paper/scanned environment, where AI and NLP will have little to no impact. What will be interesting, especially as more hospitals adopt full EMRs, is just how much improvement in documentation behaviour and quality AI can produce. There remains the unquestionable need to educate and continually engage clinicians not only in CDI, but system IQ and capability.
Need for Best Practice Standards: Despite advancements, there remains some gaps in formalised best practice guidelines and standards across various aspects of CDI. Establishing these standards will be crucial for ensuring consistent and aligned practices in healthcare settings. Whilst models exist in relation to CDI metrics, concurrent review methodology, education and clinician engagement, formal best practice standards are still being developed. Until this time, the trap is that many hospitals and health services will invent their own approach to CDI that may not align with all of the key focus areas of CDI.
Final Word
In many respects, 2023 has been a landmark year for CDI, with significant strides made towards enhancing the field's impact on patient safety, data integrity, and hospital sustainability. The anticipation for what lies ahead in 2024 is palpable, with the CDI community poised for further innovation and growth..
Here’s to another impactful year of shaping the course of CDI...…. Bring it on!
Mike Kertes, CDIA National Director