Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation

Abstract

Background

Numbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS review patient records concurrently with patient admissions and visits to ensure that information is accurate, complete and non-ambiguous, and query clinicians when they see opportunities for improving data. The occupation was initially focused on improving data for reimbursement, but rapid changes to clinical coding requirements, technologies and payment systems led to a quickly evolving role for CDI programs and changes in CDIS practice.

Objective

This case study seeks to uncover the ongoing innovation and adaptation occurring in a CDI program by tracing the evolution of a single CDI program over time.

Method

We present a case study of the CDI program at the HonorHealth hospital system in Arizona.

Results

The HonorHealth CDI program holds a unique hybrid expertise and role within the healthcare organisation that allows it to rapidly adapt to support emergent demands both internal and external to the organisation, such as supporting accurate data collection for the COVID-19 pandemic.

Conclusion

CDIS are a vital component in present data-intensive resourcing efforts. The hybrid expertise of CDIS and capacity for adaption and relationship building has enabled the HonorHealth CDI program to adapt rapidly to meet a growing array of clinical documentation integrity needs, including emergent needs during the COVID-19 pandemic.

Implications

The HonorHealth case study can guide other CDI programs in adaptation of the CDI role and practices in response to changing organisational needs.

Keywords

documentation data quality electronic clinical documentation case study health information systems health information management clinical documentation integrity data work

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