Clinical documentation improvement specialists and case managers share a common goal but often aren't on the same page when it comes to improving documentation within the hospital.
Clinical documentation improvement (CDI) programs are prevalent in many hospitals and have evolved over the years. In 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. If all surveyed facilities that planned to implement a CDI program did so, 80% of responding hospitals would have one. These numbers are likely even higher today as CDI programs become ever more relevant.
CDI programs can be a valuable bridge between clinical care and coding at hospitals. By concurrently reviewing clinical documentation in medical records and conferring with and educating providers, CDI teams continually support accurate documentation. When CDI program staff collaborate with providers and coders around improved documentation, the result is more accurate coding, reporting, quality metrics, and reimbursement.
Greater detail in clinical documentation is required since the introduction of ICD-10, making CDI efforts even more relevant. In addition, healthcare is steadily moving toward value-based purchasing and greater scrutiny from regulators and the public. With all of this in mind, it is more important than ever to get documentation and coding right. The daily activities surrounding CDI are crucial to successful outcomes and sustainability of facilities and healthcare systems.
Prevention is better than a cure. In the world of HIPAA privacy and security, training and awareness are among the most important aspects of prevention. The best laid policies and procedures won't keep your patient's PHI safe if no one knows how or why to follow them. But effective and engaging training methods can be elusive. Employees and administrators might begin to treat their annual training as routine, going through the motions to get their certificate, and then falling victim to a phishing attack that could have been avoided. New hires may be overwhelmed by the scope of HIPAA?it's a huge law?or struggle to connect it to their job duties. Developing education and awareness strategies that capture employees' attention and build privacy and security into the culture of their workplace can be a tall order.
