Key takeaways from the first CHIMA Clinical Documentation Improvement Community meeting

Key takeaways from the first CHIMA Clinical Documentation Improvement Community meeting

During the first virtual CHIMA Clinical Documentation Improvement Community (CDI Community) meeting on June 11, 2021, British Columbia-based CDI Specialist Rita Parmar facilitated a discussion among more than 20 participants who expressed their enthusiasm for how this community could address the challenges that come with working in isolation on CDI-related initiatives. Many agreed that improving physician engagement is key. One suggestion is raising awareness, with members of physician groups, about the positive impact that CDI has on patient outcomes and metrics. Sometimes that can be as simple as showing physicians the difference between a well-coded chart (with strong documentation) and a poorly coded chart (lacking documentation). Meeting participants also recognized the potential within the CDI Community to develop and provide more effective education for physicians and coding specialists.

With regards to underscoring the importance of CDI at any organization, participants emphasized how crucial it is to understand the goals of decision-makers and the need to align CDI efforts with those goals. Some recommended demonstrating before-and-after scenarios to illustrate how CDI impacts key performance indicators (KPIs) and outcomes. These could include increases in resource intensity weights (RIWs), decreases in acute length of stay over the expected length of stay (ALOS/ELOS), and the lowering of hospital standardized mortality ratio (HSMR), to name a few.

Meeting participants agreed that there is a decided lack of Canadian resources and suggested leveraging some of the more abundant American resources that currently exist and adapting them. Rita mentioned she had been in contact with the United States-based Association of Clinical Documentation Integrity Specialists (ACDIS) about sharing some of their tools, publications, guides, and other resources.

Some questions remain unanswered but surely will be addressed at future community meetings. Topics include how to raise physician awareness about how their data is being used, including secondary uses; how best to achieve data optimization; and deciphering physician handwriting and other challenges inherent in paper-based or electronic systems.

Participants in CDI’s first meeting had much to share with one another—their common experiences, challenges, and potential solutions. We hope many more individuals find support and inspiration in joining the CDI Community, because the more we share, the more our knowledge can affect positive change not just in our separate organizations, but across the health care system as a whole.

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