0130 Perspectives from three certified CDI specialists

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CHIMA interviewed three clinical documentation improvement (CDI) specialists, certified through the Canadian College of Health Information Management. Learn about their roles and the types of diagnoses regularly reviewed across their respective health care settings from British Columbia to Ontario. Susan Molloy, Shayda Khalili, and Prakash Shah share perspectives on key performance indicators (KPIs) worth monitoring, stakeholders they believe should be involved in the success of a CDI strategy and or program, patient outcomes produced from their work, and more.

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Interviewees

Susan Molloy, RN, CCDIS Nurse, Clinical Documentation Improvement Specialist London Health Sciences Centre (LHSC)

Susan Molloy is an experienced registered nurse and certified clinical documentation improvement specialist (CCDIS). She is a proud member of the original CDI team pioneered at London Health Sciences Centre (LHSC) in 2013. Susan combines 35 years of nursing clinical expertise and critical thinking skills to align with the Canadian Coding Standards (CCS) to identify physician query opportunities and education.

Susan has participated in presentations at Schulich School of Medicine at Western University, the Utilization Managers’ Network of Ontario (UMNO), the ICES research team, and with Westervelt College with their HIM students. Today Susan and the CDI team continue this education and focus on auditing opportunities.

“CDI gives me the opportunity to make a difference in patient care by encouraging clear, concise, accurate documentation. The chart is the main communication tool for all stakeholders, and CDI can make a difference by ensuring the true story and acuity of the patient is reflected. CDI also plays a role in ensuring accurate data. This data is extremely valuable, and it needs to be accurate and complete. I am proud knowing that our CDI and HIM team contribute to high-quality data.” – Susan Molloy, RN, CCDIS

“Any time I get to discuss CDI with a physician is a positive event. Initially, there may be some resistance, but once the significance of the query and the significance of CDI are explained, the physician gets on board. And actually, they get excited about the value this work has.” — Susan Molloy, RN, CCDIS

Prakash Shah, CCDIS Clinical Documentation Improvement Specialist Scarborough Health Network

Prakash Shah is a clinical documentation improvement (CDI) specialist at Scarborough Health Network (SHN) and works part-time at Hospital for Sick Children (SickKids) in Toronto, Ontario. He was the first CDI specialist to be hired at SickKids in 2019 and is certified through the Canadian College of Health Information Management. Living in Canada now for over five years, previously Prakash studied and worked in various parts of the world, including the United Kingdom, Malaysia, China, and India.

Prakash has been active in the healthcare field for over 20-years working in various roles such as general practitioner, public health lecturer, and medical officer. He has worked as a research assistant at the Centre for Global Health Research and as a physician coder, all too familiar with ICD-10, at St. Michael’s hospital.

“CDI is often linked to coding, which is very, very true. But there is an important dimension: the need to collect quality data and use it to improve hospital practices and processes, providing the ultimate benefit to patients.” — Prakash Shah, CCDIS

Shayda Khalili, CHIM, CCDIS Clinical Documentation Improvement Specialist Royal Victoria Regional Health Centre (RVH)

Shayda Khalili is a certified clinical documentation improvement specialist and health information management professional through the Canadian College of Health Information Management. She is an international medical graduate and has worked overseas as a family physician for over 17 years. Shayda also has experience in medical coding and chart management.

“As a part of my job, I have been working with physicians and coders to advance medical documentation. Recently we have seen a notable, positive outcome as documentation has drastically improved and revenue has increased due to this collaborative initiative.” – Shayda Khalili, CHIM, CCDIS

“At the moment, our CDI communities are small; however, we have a large impact in health care. With your support, we can continue to grow and expand the program.” – Shayda Khalili, CHIM, CCDIS

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