by Carolyn Riel

With CDI’s expansion into quality measures, the need for CDI programs has become apparent in countries beyond the United States. In Canada, CDI is just beginning to take off, but because Canada has a universal healthcare payment system, CDI there looks a bit different from what the U.S. is used to.

“People have been doing aspects of CDI in Canada for years; it’s just now finally becoming more well known,” says Rita Parmar, CHIM, CCDIS, CDI community facilitator with the Canadian Health Information Management Association (CHIMA) based in London, Ontario, Canada. “Full-time CDI roles are being formed with documented job descriptions.”

CHIMA created Parmar’s current position to unite everyone who does some type of CDI work or is in a designated CDI role and create a space where Canadian CDI specialists can network and collaborate.

“I had seen the job posting for a community facilitator, read through it, and thought, ‘This sounds fascinating; I would love to see what it’s about,’ ” Parmar says. “After speaking with the hiring manager, I learned it was a completely new position that would include a huge learning curve for me.”

At first, the CDI community group was small. To help it grow, Parmar says she sent out a call for participants in a monthly CHIMA Connection e-newsletter blast. After that first send, she received a surprising response of 25–30 people who wanted to participate in the community. “I knew there were more people doing CDI work out there, and finally we started to bring them together,” she says.

The new participants were immediately grateful for the support and opportunity to network. “The community is new, so we’re just trying to solidify our objectives,” Parmar says. “We’re looking for people to bounce ideas off of in terms of Canadian-specific educational resources and support this practice area within the health information profession.”

A focus on quality

Because the Canadian healthcare payment system differs from the United States’ system, Canada’s CDI work looks a bit different as well. While U.S. healthcare works on an insurance-based platform, either third party or through the government, all Canadian residents have access to governmental health insurance funded through taxes.

“British Columbia (BC) is divided into five health authorities plus the Provincial Health Services Authority and the First Nations Health Authority,” Parmar says. “The health authorities govern and provide healthcare within their region. The BC Ministry of Health distributes all healthcare funding to the health authorities.”

From Parmar’s experience, CDI specialists in Canada don’t focus on reimbursement, and instead focus on quality measures and indicators. Because so much of CDI in the U.S. is driven by reimbursement on some level, Parmar says the CHIMA CDI community has had a difficult time finding useful resources.

“We need resources that understand the structure of how our Ministries of Health for each province are funded based on patient population,” she says. “Some of the U.S.-specific CDI resources are helpful, but we need resources more tailored to the Canadian healthcare payment system.”

Much like CDI programs stateside that have expanded to include quality reviews, Canadian CDI professionals often find themselves working closely with quality and patient safety teams to review and report related analytics.

“When you’re a part of a health authority, there’s a group of indicators for the whole area that you both pull from and contribute to,” Parmar says. The health authority creates dashboards and publishes balance scorecards that look at data for the entire region—similar to the way sites like Hospital Compare or U.S. News & World Report function in the States. The CDI team will review these indicators on an ongoing basis and look at how their metrics compare to other hospitals within their region and other regions. These metrics support much of the CDI work, Parmar notes.

“Most of our work in CDI is related to quality,” Parmar says. “Quality teams will often reach out wondering about metrics and how to code including those metrics.”

When the CDI team is approached with such questions, Parmar says they try to investigate national indicators from the Canadian Institute for Health Information (CIHI), to whom such data is reported. This information gives CDI specialists a good idea of where they stand.

“They have a platform that we can tap into and use the data,” she says. “We use various tools to help us drive the work we’re doing or knowing what areas to focus on.”

A lack of technological solutions, engagement

Unlike the plethora of technological solutions available to United States-based CDI teams, Canadian CDI teams often face a dearth of such solutions.

“Right now, CDI specialists in BC don’t leverage technology for assistance, but we’re looking into a solution to help reduce manual efforts. We have an electronic health record [EHR] project being implemented in three health authorities,” says Parmar. “A lot of our work in the future is based on the implementation of an EHR system and working with the provider teams to standardize templates and provide education based on impacts.”

Provider engagement is an issue faced by many United States CDI teams. Across the country, the communication between CDI teams and physicians varies. That’s a problem for Canadian CDI professionals as well. “If there’s an issue because of the documentation, that’s a challenging piece for us because our work is at the mercy of what’s documented,” Parmar says.

This lack of consistent communication makes it difficult to foster physician engagement or build strong working relationships.

“Our hope is that when the new technology and EHR is implemented, our communication with physicians will strengthen,” says Parmar. “Right now, we try to find indicators of interest that physicians need to know, or site leads will approach us and want to look into site cases at certain hospitals.”

A need for further expansion

United States-based healthcare organizations increasingly understand the need for CDI, and that understanding has begun to appear in Canada. Many professionals had already been doing CDI work for years; it’s just now that their efforts are being recognized and called out as such.

“There’s starting to be this new level of understanding from people of quality measures and how important it is,” Parmar says. “Our physicians will go to the U.S., hear about CDI, and come back to us saying, ‘Isn’t this what you’re doing?’ ”

In addition to general quality metric reviews and other CDI tasks, CDI specialists in Parmar’s region help with support and guide the standardization of documents such as the discharge summary. When a patient goes through their hospital journey, their health information must be accurate for continuity of care. Understanding the complexity of health data, and ensuring its accuracy, is where CDI specialists step in.

“There are varying standards, but we need them to be the same when on the patient chart,” Parmar says. “That’s why we created the discharge summary worksheet to capture additional cause codes that may have been missed, as the discharge summary is supposed to be the whole story.”

“We’re hoping that collaboration between clinical and coding teams will promote the message of the importance of quality documentation and how it affects not only the physicians, but all healthcare staff and, more importantly, the patient,” she adds.

“With the implementation of the EHR, we are hoping to get more engagement with physicians as more data becomes readily available,” Parmar says.

Part of the process includes getting coders involved and asking for their documentation challenges and any specific areas for CDI teams to focus on.

“We are trying to take our retrospective studies forward to the leadership teams to showcase the positive results of focusing on CDI,” Parmar says. “In an ongoing effort, the CHIMA CDI community will be discussing ways to approach leadership about the adoption and implementation of CDI programs. CDI is starting to gain traction and recognition, and we want to keep that momentum going.”

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Editor’s note: All are welcome to join the CHIMA CDI Community quarterly meetings to forge a collaborative relationship between CDI specialists in the United States and Canada.

This article originally appeared in CDI Journal, a publication of the Association of Clinical Documentation Integrity Specialists (ACDIS), and was republished by CHIMA with their permission.