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CDI Week Q&A: CDI and Technology

Wall, James

James Wall, RN-TN, BSN, MBA

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. James Wall, RN-TN, BSN, MBA, the senior director of clinical documentation improvement at LifePoint Health in Brentwood, Tennessee, and a member of the 2017 CDI Week Committee, answered these questions on CDI and technology. Contact him at

Q: How long have you had electronic health records?

A: I am a systems Senior Director of CDI. Since LifePoint has acquired many hospitals, we have assumed a variety of different EHR systems. While there is not a standard EHR, LifePoint uses three main Health Information Systems. Many of our hospitals are totally electronic while others are a hybrid of EHR and paper.

Q: Have there been any real sticking points with the transition to full electronic systems? [more]

Guest Post: Natural language processing and clinical documentation, part 2

CDI and technology

New technology heavily affects CDI and coding.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Effect on coders

Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP) technology, coding’s job becomes much easier. From the physicians/providers to the CDI specialists, NLP helps ensure documentation is robust, with conditions that have been queried when necessary and fully specified—producing a fully documented encounter by the time the chart crosses the coder’s desk.


Guest Post: Natural language processing and clinical documentation, part 1

CDI and technology

Many clinicians now use dictation software and EHRs.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Long before ICD-10-CM/PCS became a focus, working as a clinical documentation improvement (CDI) manager to improve physician progress and/or operative notes was a challenge—doctors either got it or they didn’t. But as the transition from paper charts to an electronic health record (EHR) began, providers started to understand how to better document their visits, since they had to choose from drop-down menus and multiple options to complete their notes. Then, as ICD-10 approached, a new awareness of medical necessity denials and revenue impact took shape. Providers began looking for ways to document better in less time.


Tip: Advance CDI’s cause through technology

CDI and technology

Technology changes the way CDI operates every day.

Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.

Then, electronic health records (EHR) came on the scene, changing the CDI process for nearly everyone.

“Simply put, the advent of EHRs and e-queries changed how CDI specialists work—and the days of misplaced paper queries and incoherent penmanship are all but gone,” according to a special report out from ACDIS and HealthLeaders Media, in partnership with Optum360, “Leveraging technology to advance CDI efforts.”

Like all changes, EHR comes with rewards and challenges. CDI programs gain the flexibility and supportive data to meet the needs of the healthcare systems they serve. All while increasing productivity.

“With any new system, issues are going to have to be addressed,” Kathy McDiarmid, RN, CDI specialist at Beverly Hospital, a member of the Lahey Health System in Massachusetts, told the CDI Journal in December.

“There will be little things that physicians forget,” she says. Yet armed with intimate knowledge of the programs chosen, CDI staff can help physicians navigate the EHR and provide real-time assistance once the programs are in use, says Colleen Stukenberg, RN, MSN, CMSRN, CCDS, director of resource management at FHN in Freeport, Illinois, in a 2016 CDI Week Q&A for ACDIS.

In order to fully leverage the new technology, according to the report, CDI specialists need to understand the technology first. This knowledge gives them another platform from which to reach out to physicians. The CDI team can be a resource and help ease the transition to a new system for the physician.

To learn more about leveraging your EHR system to improve physician engagement and productivity, read the entire report by clicking here.

Note from the Instructor: Are you a critically thinking CDI?


Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.

This all sounds great, but I think such technology may also be a hindrance when training new staff.

Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.

Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.

We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.

Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community ( describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”

My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.

Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.

Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at This article originally appeared in CDI Strategies.

Guest Post: Be wary of EHR ills


Darice M. Grzybowski

by Darice M. Grzybowski, MA, RHIA, FAHIMA

I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the coding director. She expressed great concern about how the documentation no longer tells the story of the patient in a clear way. And, she wanted to know, why more isn’t being done to remedy the problem.

To fix any problem, one must understand why or how it occurred. Obviously clinicians don’t try to create worthless, redundant, and conflicting documentation. Vendors don’t try to develop systems that are poorly designed and which may lead to errors in interpretation, redundant notes, and impossible to read printed formats. Most poor documentation problems are unintentional and occur because vendors lack an understanding of how to develop a properly formatted, output-based, episodic-driven medical record.

Another concern is that problematic technology enables poor documentation habits. I was recently told by an EHR vendor that they purposely designed options where information from historical labs could be pre-populated into current history and physicals (H&P) and progress notes as an efficiency measure.

The beauty of electronic documentation is that users should be able to see existing lab values, historical problems, or medications without copying it into a note. The problem of pushing forward old information, either within a visit, from a previous visit, or upon request of a clinician, is wasteful and at times dangerous when the reader of the note may mistakenly interpret an old lab value as a current one.

The following examples illustrate the dangers associated with technology that enables poor documentation habits:

  • Allowing copy and paste continues to cause note bloat in the printed format as well as electronic. When printing these records, the poor formatting makes it nearly impossible to interpret the documented values. And yes, the majority of medical records are printed in one way or the other for various reviews and release of information just so that someone can look at a complete record without flipping endlessly through fragmented screen templates. This is often a surprise to most of the clinicians and information technology staff who are later shocked when budgets for paper and toner are continuing to increase.
  • Inappropriate EHR functionality such as “sign all” allows providers to authenticate orders and reports, which often results in signing off on clinical documentation queries without actually reading them. This type of functionality allows ill-designed system proliferation of burst-apart standing orders to continue, rather than be identified and corrected. Adding further functionality of automatic release of such documents then creates proliferation of duplicative notes and orders to other facilities and practitioners.

Editor’s Note: Grzybowski is the president of HIMentors, LLC, and the 2015 recipient of the AHIMA Triumph Award for Literary Legacy. For informatino, visit her website or email This article originally appeared in the October edition of Medical Records Briefings.

Is your EHR on the right track?

What lesson learned do you have to share? Your peers are waiting to hear your insight. Submit your ideas for the 2014 ACDIS National Conference now.

Take this survey!

Dear healthcare professional,

Medical Records Briefing (MRB) is conducting it’s a benchmarking survey on electronic health record implementation, and we would appreciate your input. Please take a few moments to complete this survey.

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Entering your contact information will also enable us to email you the results of the survey along with commentary from industry experts. The results will also be featured in the October 2015 issue of MRB.

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Jaclyn Fitzgerald
Editor, Medical Records Briefing


News: Physician group offers position paper on EHR use

ICD-10 testing process in play

ACP offers EHR insight

There’s no arguing that the face of physician documentation has changed and will continue change under ongoing advances in electronic health records (EHRs), according to a new position statement from the American College of Physicians (ACP) which recommended limitations on copy/paste, increased emphasis of open-dialogue versus structured data, and further study of the effectiveness of electronic health records, among other items in its recent position paper on clinical documentation in the 21st Century.

With increased EHR use comes increased information—both useful and sometimes unwieldy. Longer, denser records often leads to difficulties in finding the most pertinent information necessary for all parties involved.

Physicians need to leverage EHRs’ capabilities to improve patient care including:

  • effectively displaying historical information in rich context
  • supporting critical thinking
  • enabling efficient and effective documentation
  • supporting appropriate and secure sharing of useful and usable information with others

“These features are unlikely to be optimized as long as the format and content of clinical documentation are primarily based on coding and other regulatory requirements,” the paper states. “Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.”

Editor’s Note: For additional information consider reading the following related articles:


News: AHIMA outlines steps for data governance

AHIMA releases recommendations for data governance

AHIMA releases recommendations for data governance

AHIMA unveiled its recommendations for healthcare information governance during its annual conference in San Diego earlier this month.

Information governance (IG) or data governance refers to the management, compliance, and control of health information in a given organization. AHIMA principally focuses on the management of medical records but the release of its recommendations broadens its scope to coverage of data information of all types within the healthcare setting, according to a Modern Healthcare report.

AHIMA’s recommendations state that IG efforts maybe more lax than necessary and that HIM professionals should work to educate stake holders on the need for interdisciplinary collaboration on policies and procedures, including engaging administrators to set strategies and priorities for the overall effort, according to a report in For the Record magazine.

According to an article in Fierce HealthIT, the framework focuses on the following eight principles:

  1. Accountability: An accountable member of leadership will oversee the program.
  2. Transparency: IG processes and activities will be documented in an open and verifiable manner.
  3. Integrity: Information will be managed in a way to provide a reasonable guarantee of reliability.
  4. Protection: Appropriate levels of protection will be provided from breach, corruption, and loss.
  5. Compliance: The program will be designed to comply with applicable laws, standards, and organizational policies.
  6. Availability: Information will be managed to ensure timely, accurate, and efficient retrieval.
  7. Retention: Data will be kept for the appropriate period based on legal, regulatory, and other requirements.
  8. Disposition: Data that is no longer required will be disposed of in an appropriate and secure manner.

News: CMS allows ‘meaningful use’ hardship exception applications

CMS offers IPPS proposal.

CMS offers EHR extension.

CMS recently announced that it will once again allow eligible hospitals and professionals to submit meaningful use hardship exception applications. The new deadline for submitting applications is November 30, 2014. The previous deadlines were April 1, 2014, for eligible hospitals, and July 1, 2014, for eligible professionals.

Eligible hospitals and professionals can submit a hardship application by the new deadline if they were unable to fully implement 2014 edition certified EHR technology (CEHRT) due to delays in the availability of the technology. In addition, the application process is open to eligible professionals that could not attest to meaningful use by October 1, 2014, and eligible hospitals that could not attest by July 1, 2014, using the options in the CMS 2014 CEHRT Flexibility Rule.
The Recovery and Reinvestment Act of 2009 requires that CMS apply payment adjustments for eligible hospitals, eligible professionals, and critical access hospitals that are not meaningful users of CEHRT. However, the act also permits CMS to conduct case-by-case reviews of organizations that apply for hardship exceptions.