What is CDI in Healthcare?

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A health information manager works on a laptop.Professionals in health information management lead healthcare organizations in the implementation and development of comprehensive clinical documentation improvement (CDI). The healthcare industry relies on patient documentation that provides clarity, consistency and benefits the overall outcome of patient care.

Professionals with an advanced degree in health information management develop documentation strategies to help healthcare facilities meet their care delivery goals on a consistent basis.

Defining CDI

Successful healthcare facilities provide patients with high-quality, cost-effective care. Generally, patients have the option to choose which healthcare facility to use, which makes the industry incredibly competitive. Healthcare facilities and organizations can benefit from hiring professionals with experience in health information management who can optimize clinical documentation improvement.

What is CDI in healthcare? The American Academy of Pain Medicine defines CDI as a system of improvements that enable medical professionals, staff and healthcare facilities to effectively manage and streamline processes relating to patient health records. CDI provides healthcare facilities with the tools to accurately utilize data to improve patient care and provide financial support in acquiring reimbursements.

For example, CDI benefits healthcare facilities that need to improve their case mix index (CMI). CMI measures the overall cost of treating a patient who is covered by Medicare. CDI strategies enable these facilities to accurately identify the treatments these patients receive as well as their overall health condition. Accurate documentation enables facilities to accurately bill for services provided, which helps lower CMI.

By improving patient outcomes through CDI, healthcare facilities can use patients’ electronic health records (EHRs) to provide more efficient health delivery, better financial tracking and improved data quality. These three areas have the potential to positively impact overall patient care.

Efficient Health Delivery

Healthcare facilities can provide patients with more efficient health delivery by using CDI implementations to triage the most urgent cases. This can offer at-risk patients timely medical attention, which can improve outcomes and mitigate mortality rates.

Better Financial Tracking

Effective CDI enables healthcare facilities to track costs and maximize profits. Medical professionals use codes such as ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) to classify healthcare symptoms, procedures and diagnoses, and record each treatment a patient receives. CDI specialists streamline and troubleshoot this process, which means that medical professionals save time on completing forms, and financial departments accurately bill for treatments and services.

Improved Data Quality

Data quality depends on the accurate inputting of medical information into EHRs. CDI strategies enable professionals to meticulously enter coded data related to a patient’s treatment. Accurate data helps everyone on the medical care team understand a patient’s status, and helps prevent malpractice due to illegible handwriting or unclear patient notes in an EHR.

CDI and Health Information Management

Professionals interested in health information management can also apply CDI strategies to improve the quality of EHRs, interactive mobile apps and telehealth services.

According to a recent study in the Annals of Internal Medicine, physicians spend an average of about 16 minutes on EHRs after each patient visit. By improving the process with streamlined templates and ICD-10-CM codes, physicians can spend more time providing patient care as opposed to committing valuable time to data entry.

Healthcare professionals can apply CDI to interactive mobile apps, using software that enables patients to access their physicians’ notes, make appointments and fill prescriptions. CDI can also provide physicians and patients with an overall greater telehealth experience. For example, CDIs can enable physicians to access patient records while conducting telehealth appointments. Integrated telehealth platforms also allow patients to acquire care remotely.

Further, CDI can provide protection for practitioners from malpractice lawsuits relating to telehealth services by providing a digital trail of treatments and services provided. Medical professionals can use CDI to assess whether patients on Medicare meet telehealth billing requirements. Improved documentation through CDI can also support financial departments in defending Medicare telehealth payments during audits.

Skills and Tools for Effective CDI

Professionals in health information management roles exhibit a variety of analytical, technical and critical thinking skills that are advantageous to developing effective CDI strategies.

  • Analytical: Health information managers use analytical skills to develop CDI strategies to streamline healthcare facilities’ policies and procedures. They may use patient satisfaction surveys to identify areas that need improvement within the facility, as well as provide quality metrics for physicians. They use this data to help develop more effective strategies pertaining to workflow, such as incorporating templated documents. These documents help medical professionals save valuable time between patients, which leads to more or longer patient visits and can lead to improved efficiency.
  • Technical: Health information management professionals must develop the necessary technical skills to implement CDI strategies, studying the latest developments in CDI toolkits, software and the ICD-10-CM codes for various health conditions. Proficiency with artificial intelligence (AI) technology, natural language processing and voice recognition software can all help improve document management.
  • Critical Thinking: Professionals who take on CDI implementation must identify their organizations’ needs and use critical thinking skills to develop strategies to meet those needs. They must also ensure that solutions such as document-tracking software integrate with EHRs and are HIPAA compliant.

CDI During COVID-19

Health information management professionals have played a key support role during the COVID-19 pandemic. The American Health Information Management Association developed two “COVID-19 query templates” to help medical professionals input and track the necessary information to document the virus’s impact on patient health.

The Centers for Disease Control and Prevention (CDC) has also developed standardized ICD-10-CM codes to address the healthcare concerns and symptoms of COVID-19. For example, the CDC assigned the code Z11.52 to represent “encounter for screening for COVID-19,” while the code Z20.822 means “contact with and (suspected) exposure to COVID-19.” The implementation of CDI can help medical professionals mitigate the effects of COVID-19 as well as future pandemics.

Discover How CDI Informs the Development of Health Information Management

Professionals interested in CDI and implementing HIPAA-compliant strategies to improve care would do well to consider an advanced degree in health information management.

The University of Illinois at Chicago’s online Master of Science in Health Information Management (MSHIM) offers students the opportunity to develop the knowledge base and skill set to excel in leadership positions in health information management.

Individuals in the MSHIM program take a range of courses in subjects such as Health Information Technology and Systems, Health Information Management Theory and Practice, Health Information Analysis and Design and Health Information Research Methods and Evaluation.

Discover how the University of Illinois at Chicago can prepare you for a rewarding career in healthcare, developing CDI strategies and making a difference in patients’ lives.

Recommended Readings

Networking Tips for a Career in Healthcare: Putting Your Best Foot Forward

What Is Healthcare Compliance? Exploring a Core Concept in Care Delivery

Human Anatomy and Physiology Study Guide


American Academy of Pain Medicine, What Is CDI and How Does It Impact You?

American Health Information Management Association, AHIMA Develops Tools to Help Clinical Documentation Integrity Professionals During COVID-19

American Medical Association, “AMA Digital Health Research: Physicians’ Motivations and Requirements for Adopting Digital Health Adoption and Attitudinal Shifts from 2016 to 2019.”

Annals of Internal Medicine, “Physician Time Spent Using the Electronic Health Record During Outpatient Encounters.”

Becker’s Hospital IT, How Hospitals Can Use CDI to Navigate the Value-Based Care Transition: 5 Insights

The Centers for Disease Control, New ICD-10-CM code for the 2019 Novel Coronavirus (COVID-19), December 3, 2020

The Centers for Disease Control, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

EHR Intelligence, What Are the Benefits of Clinical Documentation Improvement (CDI)?

Fierce Healthcare, For Each Patient Visit, Physicians Spend about 16 Minutes on EHRs, Study Finds

Florida Hospital Association, Clinical Documentation Improvement Program

G2, Best Clinical Documentation Software

HealthCareDrive, AMA Survey Shows More Doctors Embracing Telehealth

HealthITNews, Health Data Management Trends to Watch in 2018: CDI, Security Lead the List

Medical Group Management Association, Navigating Telehealth Billing Requirements

ScribeKick, How to Improve Your Case Mix Index