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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.

Q&A: Technology

Ask your question!

As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Joy Coletti, MBA, RN, CCDS, system services director for clinical documentation improvement at Memorial Hermann in Houston, Texas, answered these questions on electronic health records. Contact her at

Q: How long has your facility been using electronic health records? 

A: It was phased in at each hospital over a one to two-year timeframe in early 2000. Two of our smaller community hospitals took the lead with engaged physician champions.

Q: What role did you personally play in the transition? How big a role did the CDI team play?

A: CDI did not really play a role in initial EMR adoption, unfortunately, other than [providing input on] how physicians are electronically prompted when they have a query, and where those query responses reside in the EHR.

Q: What was the impetus for the transition initially (ICD-10? Government imitative?)?   

A: HIPAA was likely a large factor in speeding up the transition. E-queries were implemented in 2010. By 2010 the EMR was more electronic than paper, but still a hybrid of the two.

Q: Can you describe the different systems you use for your EHR and e-Queries? 

A: EHR is a Cerner platform, but also has Intelligent Medical Objects which allows us to search diagnoses. For e-queries, CDI specialist and coders software were developed by Meta Health, now part of Streamline Health.

Q: Has EHR use led to remote CDI capabilities?  

A: Yes, but within each hospital. Records are reviewed from an office location rather than within the units. This has significantly improved productivity levels. Records can also be reviewed across hospitals for coverage capabilities when a CDI specialist is out of the office or when census is very high at certain facilities. I hired three regional float CDI specialists who support multiple hospitals remotely from their offices on one hospital campus. Each CDI float supports multiple facilities and provided backup coverage.

Q: What has been the biggest benefit from EHR implementation in your opinion? 

A: Legibility of documentation, the ability for many disciplines to access the record simultaneously, remote access, and quicker order entry with fewer errors.

Q: What has the CDI team struggled with most in terms of reviewing records in the EHR and helping physicians with their documentation?

A: First, fragmentation of the EHR, which makes it challenging for physicians to “tell the patient’s full story” in an accurate and efficient manner. Providers sometimes produce a lot of copy-and-paste generated notes, which are challenging for CDI specialists and coders to follow and understand the patient’s story.

Second, there are no central diagnosis or problem lists managed by physicians that can be used by CDI specialists and coders.

Q: What advice would you give to CDI specialists who might be just starting EHR implementation or struggling through the process?

A: Continue to use paper queries until the EHR is at least 50% electronic, or at least a majority of history and physicals and progress notes are electronic. Once you transition to e-queries, while the health record is still hybrid, place a paper query “prompter” in the paper record to alert providers they have an electronic query, the basic steps for how to answer that e-query, and, of course, the CDI specialist’s name and contact information.

Q: What contingency plans are in place for when the power goes out or internet goes down? (you can skip this question if you want, I’m just curious in light of the flooding in LA and the fires in CA and knowing what happened in NYC after Sandy.)

A: Luckily, our back-up generators have always kicked in. All generators were moved out of basement level years ago due to the history of flooding in Houston area. Our IT emergency plans kick in when the EHR goes down and “all hands on deck” until the issue is identified and the EHR is back up and running. In the past, we were able to be back up within two hours.

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.

TBT: EHR implementation stories from the CDI front lines

AHIMA releases recommendations for data governance

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we’re throwing it back to an article from last January’s CDI Journal, “EHR: Three implementation stories from the CDI front lines.”

When Bernadine Darienzzo, RN, CCDS, CDI supervisor at Boston Medical Center (BMC), started at the 496-bed academic facility three years ago, the team had to carry their laptops to the hospital floors due to a lack of available floor computers and work space. This arrangement led to communication problems. Laptop batteries would run out in a matter of hours, and it proved difficult to review charts and engage in conversations with the physicians during patient rounds.

“We tried to tag along, but rounds are fast paced and focused on daily orders and discharge planning. Physicians had mostly just come from seeing their patients, so they were not going directly back to the charts. It just wasn’t the place or time for us,” she says.

BMC is a private, not-for-profit facility and one of the busiest trauma centers in New England, says Darienzzo. The physicians supported the new program, but they felt it was disrupting patient care.

As BMC became one of Boston’s first facilities to integrate an EHR, the CDI process migrated away from a floor-based approach.

After BMC migrated to a fully electronic query system, Darienzzo worked with BMC’s IT team and the vendor to ensure physicians received queries in an effective yet unobtrusive manner. The IT team made sure that whenever physicians entered the EHR to update their progress notes, they first saw the queries attached to the note. They would read the content of the query, then scroll down to write their note.

According to Darienzzo, the positive outcomes of this new process were immediately apparent. They included:

  • A 70% decrease in follow-up queries
  • A 98% physician query response rate
  • Giving physicians the ability to respond to queries when and where they document their progress note (e.g., in the office, at home, or on the floor) rather than having to remember a query and find it in an alternative system

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:


Guest Post: EHR just one piece of the documentation puzzle

by Alexandra Wilson Pecci

EHRs alone don't solve documentation problems.

EHRs alone don’t solve documentation problems.

How nurses and doctors communicate—or don’t communicate—using health information technology is the focus of a multi-year study funded by the federal Agency for Healthcare Research and Quality.

The life-and-death importance of nurse-physician communication and the use of electronic health records came to a frightening, critical head last week when a nurse noted in a sick patient’s EHR that the patient had recently traveled to the United States from Africa.

Despite the note, the patient was sent home. He later returned to the hospital and was eventually diagnosed with the Ebola virus.

Revising an earlier statement that blamed the bungled incident on a “flaw” in its (Epic) EHR system, Texas Health Resources backtracked last Friday saying, “As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.”

In either event if the nurse used the EHR alone to communicate that critical piece of patient information, it obviously didn’t work. According to Milisa Manojlovich, PhD, RN, CCRN, associate professor at the University of Michigan School of Nursing, it’s a case of the medium not matching the message.

Editor’s Note: This article originally published in HealthLeaders Media, October 7, 2014.

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.

Free Optum webcast rescheduled for CDI Week; additional free webinar on PSI and CDI offered

Join us this for these free audioconference/webinars

Join us this for these free audio conference/ webinars.

Natural language processing (NLP), an emerging technology for CDI professionals, can help drive clinically relevant queries and optimize physician engagement in your CDI program. Learn how Optum360™ case finding technology, powered by LifeCode® NLP technology, can transform your CDI program during this free one-hour webinar on September 17, 1 to 2 p.m. ET.

Join Kelly Gates, RN, MHA, CCDS, and Tom Darr, MD, as they showcase the “next generation” of CDI software, expanding on how technology can perform checks and balances between documented diagnoses and clinical indicators. This enables CDI specialists to quickly and efficiently review potential query opportunities. Clinical indicators identified by the technology route to the CDI specialist for review, and are automatically included in the physician query. These new tools optimize manual tasks, and result in improved response and adoption by physicians.

Click here to learn more about this webcast.

In addition, to kick off CDI Week, ACDIS is offering a 60-minute free webcast on Tuesday, September 16, at 1 p.m. (ET) regarding the role of CDI specialists in review of Patient Safety Indicators (PSI) on a concurrent basis. Join Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer, as she explains PSIs and their function as well as the CDI specialists’ role in their review. The program will also take a deeper dive into PSI 90 to help CDIs focus on the required documentation elements in the medical record and provide practical tips for working in conjunction with quality.

If you have any questions, please contact our customer service department at or call 800-650-6787.

TBT: CDI input helps EHR implementation succeed

Learn how new technologies will affect CDI efforts in this week's free webinar.

CDI involvement in EHR implementation is key.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the April 2012 edition of the CDI Journal.

“We saw the EHR train as it was whisking by. We were shouting ‘Wait! Wait! What about CDI?’ ” says one CDI specialist. “They didn’t know CDI existed. The [implementation team] hadn’t thought about us and how we interact with the record or what we might need from an electronic system. So now we’re trying to play catch-up and do the best we can with what we’ve got.”
CDI specialists probably think phrases like “interoperability” and “meaningful use” need not cross their minds—EHR implementation belongs in the hands of the IT or HIM department, right? The answer to that question is yes and no, says Barbara Hinkle-Azzara, RHIA, (formerly) Vice President of Operations for Meta Health Technology in New York City. The individual end-user (i.e., the CDI specialist reviewing medical records on the hospital floor) “may not need to be involved in ‘checking off the boxes’ to certify meaningful use is met, but certainly adapting to an EHR and adhering to meaningful use requirements affects the information CDI professionals review and how they will ultimately perform their jobs.
“EHR systems will change the CDI specialists’ experience,” she says.
A CDI program director or physician champion can play a pivotal role in the implementation of initial and ongoing assessment efforts for EHRs and their components, says John Pettine, MD, FACP, CCDS, CDI director at Lehigh (PA) Valley Health Network.
“CDI staff should get involved and do it now before it is too late. Otherwise, CDI professionals are at the mercy of decisions made without their input, which can be tragic to the success of the program going forward into ICD-10,” he says.

Free Optum360 webcast scheduled

Join us Sept. 3, for this free webinar presentation.

Join us Sept. 3, for this free webinar presentation.

Natural language processing (NLP), an emerging technology for CDI professionals, can help drive clinically relevant queries and optimize physician engagement in your CDI program. Learn how Optum360™ case finding technology, powered by LifeCode® NLP technology, can transform your CDI program during this free one-hour webinar on September 3, 1 to 2 p.m. ET.

Join Kelly Gates, RN, MHA, CCDS, and Tom Darr, MD, as they showcase the “next generation” of CDI software, expanding on how technology can perform checks and balances between documented diagnoses and clinical indicators. This enables CDI specialists to quickly and efficiently review potential query opportunities. Clinical indicators identified by the technology route to the CDI specialist for review, and are automatically included in the physician query. These new tools optimize manual tasks, and result in improved response and adoption by physicians.

Click here to learn more about this webcast.