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Artificial Intelligence Is a Game-Changer for Clinical Documentation Integrity

By Katherine Lusk, MHSM, RHIA, FAHIMA

When clinical documentation integrity (CDI) is managed by certified health information professionals, it can lead to improved patient care. That’s why AHIMA and 3M Health Information Systems recently hosted a panel where clinicians and CDI professionals explored how artificial intelligence (AI) and other technology advances can improve patient care. The resulting white paper, “Elevating Clinical Documentation Integrity with Compliant Technology Adoption,” focuses on how health care systems can use technology, specifically AI-enabled computer-assisted physician documentation (CAPD), to achieve data integrity and compliance, enhance workflows, and improve value-based care models.

The benefits of CAPD are numerous. It removes some administrative burden from physicians, allowing them to spend more time with patients. With physicians spending as much or more time documenting patient encounters as treating patients, it’s no surprise many have reported experiencing burnout. “Now, AI-enabled CAPD facilitates a timelier review, delivering real-time clarification requests, or prompts, to clinicians as they document the patient encounter to help them provide an accurate and complete overview of their interaction,” the paper states.

Of course, the panelists noted that CAPD alone cannot ensure sustained physician engagement in the CDI process. The panelists said peer-to-peer education led by physicians who buy in and can serve as “champions” is especially important. This education should come as early as is feasible, and residents are an especially key group to target. “Explainability—creating an understanding of how information in the health record is used both within and outside of the organization—sheds light on CDI’s central role in enhancing quality and patient safety and achieving operational objectives,” the paper notes.

Elizabeth Guyton, a vice president at 3M Health Information Systems, said CAPD’s impact on CDI can be significant. “CDI programs supported by AI are able to deliver more complete and accurate data to providers in real time, which helps close gaps in clinical documentation and care delivery,” Guyton said in a press release announcing the white paper. “With CAPD, physicians have more time to focus on patient care.”

Accurate and Complete Data
CAPD positively impacts patient care by helping ensure accurate, complete, and actionable data. Physicians’ ability to make sound decisions is predicated upon having accurate documentation in patient health records. Put simply, the more accurate health information physicians have access to, the better decisions they can make.

In addition to improving patient care, according to the white paper, CAPD can help CDI teams “track physicians’ response rates to prompts and queries and record the clinical evidence that supports final documentation and coding, reducing fraud, waste, and abuse in the billing process. With the inclusion of CAPD technology, the role of CDI is elevated to support quality improvement by closely monitoring quality indicators, such as AHRQ’s Patient Safety Indicators and prevalence of hospital-acquired conditions.”

CAPD can also have a positive effect a health system’s revenue cycle. Because CAPD improves how care is documented, a patient’s record will be more complete at discharge, improving the efficiency of the revenue cycle.

CAPD is a health care game-changer, but it doesn’t mean that manual queries can be ignored. They’re still necessary for complex cases. “Manual queries allow for greater interpersonal interaction and provide CDI professionals an opportunity to reinforce CDI’s importance and help change the culture of documentation,” according to the white paper.

Looking Forward
This is an exciting time to work in health information. Emerging AI technologies such as CAPD allow health information professionals to learn new technical skills while improving patient care and operations at their respective health systems.

Some readers may be familiar with the Institute for Healthcare Improvement’s Triple Aim initiative, which has the objective of improving the patient experience of care through better physician engagement and outcomes, lowering health care costs through better care coordination, and improving the health of populations by supporting value-based care delivery. It’s clear to both me and the panelists that CAPD meets each of these three objectives.

I look forward to seeing how AHIMA members and health information professionals will use CAPD and other AI-assisted technologies to deliver more complete and accurate data for their organizations. Together, we can improve care and decrease inefficiencies. The white paper from AHIMA and 3M is available at ahima.org.

— Katherine Lusk, MHSM, RHIA, FAHIMA, is president/chair of AHIMA.