AHIMA, AHA Connect ICD-10, Clinical Documentation Improvement with Better Care | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

AHIMA, AHA Connect ICD-10, Clinical Documentation Improvement with Better Care

August 8, 2014
by John DeGaspari
| Reprints
Two healthcare leaders share strategies for clinical documentation improvement at AHIMA CDI Summit

There is significant value in Clinical Documentation Improvement (CDI) in and of itself, according to Sue Bowman, senior director, coding policy and compliance at the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen, director of coding and classification at the American Hospital association (AHA). Their comments were delivered this week at AHIMA’s annual Clinical Documentation Improvement Summit in Washington, D.C. Both said that, paired with the greater specificity of ICD-10, CDI can promote better patient care and lead to more accurate captures of acuity, severity and risk of mortality.

Bowman and Leon-Chisen noted the important effect ICD-10-CM/PCS has on CDI, as well as other external forces such as healthcare reform, electronic healthcare record adoption and pay-for-performance standards. Quality documentation and data are foundational to national healthcare initiatives aimed at improving care and lowering costs, including meaningful use, accountable care organizations, and value-based purchasing. A good clinical documentation improvement program can ease the transition to ICD-10, they said.

EHR documentation prompts and templates can be used to facilitate complete and accurate documentation, including capture of increased specificity needed for ICD-10 codes, accordfing to the speakers. “These templates will let physicians spend more time on patient care and less time on clinical documentation,” Bowman said. “EHR templates will ease the ICD-10 transition for all involved and provide greater coding accuracy, productivity and coder and physician satisfaction.”

The pair also shared strategies for healthcare organizations looking to initiate CDI programs. They emphasized the overarching goal is not a greater volume of clinical documentation but better and more efficient documentation. Strategies include:

  • Identify documentation improvement opportunities that could affect various initiatives including ICD-10, Meaningful Use, value-based purchasing, present on admission and hospital acquired condition reporting.
  • Determine the best solution for addressing each documentation gap – one size doesn’t fit all.
  • Prioritize - start with ‘low hanging fruit’ or issues with greatest potential to make a difference.
  • Educate medical staff.
  • Demonstrate to physicians the value of high-quality documentation.

 

Get the latest information on Health IT and attend other valuable sessions at this two-day Summit providing healthcare leaders with educational content, insightful debate and dialogue on the future of healthcare and technology.

Learn More

Topics

News

MGMA: Physician Compensation Data Illustrates Nationwide PCP Shortage

Primary care physicians’ compensation rose by more than 10 percent over the past five years, representing an increase which is nearly double that of specialty physicians’ compensation over the same period, according to the Medical Group Management Association (MGMA).

Circulation, Buoy Health Collaborate on Integrated Platform for Patient Transportation

Boston-based startup Circulation Health, a ride-ordering exchange that coordinates medical transportation logistics using Lyft and other transportation partners, is partnering with Buoy Health, also based in Boston, to integrate their platforms to provide patients with an end-to-end healthcare experience.

HITRUST Provides NIST Cybersecurity Framework Certification

The Health Information Trust Alliance (HITRUST), security and privacy standards development and accreditation organization, announced this week a certification program for the National Institute of Standards and Technology's (NIST) Cybersecurity Framework (Framework).

Report: Interoperability in NHS England Faces Similar Barriers as U.S. Healthcare

Electronic patient record interoperability in NHS England is benefiting patient care, but interoperability efforts are facing barriers, including limited data sharing and cumbersome processes falling outside of the clinician workflow, according to a KLAS Research report.

Geisinger National Precision Health Hires Illumina Exec to Lead Business Development

Integrated health system Geisinger has hired a high-profile genetic counselor to head up business development for Geisinger National Precision Health, which was created to extend the Geisinger model on the national scene.

$30M VC Fund Launched to Spur Innovation in Cardiovascular Care

The American Heart Association, together with Philips and UPMC, has announced the launch of Cardeation Capital, a $30 million collaborative venture capital fund designed to spur healthcare innovation in heart disease and stroke care.