Implementing a CDI/CDS project
Two employees discuss the data shown on a monitor

How do you imbed a CDI program and CDS?*

There’s no straight answer

*Clinical Documentation Improvement and Clinical Documentation Specialist

If your Hospital Information Services (HIS) department has decided it’s time to put a Clinical Documentation Improvement (CDI) program in place, backed with one or more Clinical Documentation Specialists (CDS), you could well be wondering where to start.

The short answer is there’s no definitive way of determining the steps for such a project. CDI is a relatively new administrative process in Australia which is evolving all the time. And because every hospital has unique requirements, its implementation is dependent on a needs-based approach.

That said, there are a number of important considerations you’ll need to take into account prior to putting your business case forward to the leadership team.

In this final article of our CDI/CDS series, we look at determining the functionality of your CDI and CDS and how they can enhance operations in the sectors you need them most.

Recapping the benefits of a CDI and CDS

In our previous articles, Is Implementing a CDI Program and Hiring a CDS really worth it? and Clinical Documentation: It improves workflow enormously, we examined the functionality of a CDI and how it can improve reimbursement and operational procedures within hospitals.

Effectively, a CDI program catches problems with coding early – making it less likely for private health insurers to block claims.

Without a CDI program, it can be difficult for coders to get the complete picture and clarification on casemix procedures – as many of the clinicians who worked on the cases either aren’t available when the coders need to talk to them, haven’t got patient records in front of them, or are simply too busy to talk.

With a CDI program, accurate documentation is supplied to the coder within a timely manner. And, having a CDS to oversee the CDI program will ensure that:

  • The documentation’s language meets coding requirements
  • Any anomalies in the notes are picked up
  • All episodes and patient history is included
  • Questions are answered quickly

This is only possible because the clinical documentation specialists work shoulder to shoulder with clinicians and tend to have a good medical understanding themselves.

From an operational perspective, a CDI/CDS program can also deliver:

  • Enhanced patient care within the hospital
  • Improved communication between clinicians and nursing staff
  • Netter ongoing care from allied professionals and other third-party carers
  • Complete and accurate case records within the HIS department for historic auditing
A male employee inputs data

Implementing change

As mentioned earlier, there’s no specific way you should design your CDI program and how your CDS works with it. However, when developing a business case for a CDI/CDS, it’s recommended that you put it forward as a project.

Since many CDI projects can achieve return on investment quickly, the cost of a CDS can become negligible – so substantiating the financial benefits may be the most straightforward part of the process once you’ve reviewed the numbers.   

Other considerations for your business case should include:

Selecting the right CDS for your needs

For some hospitals, this may come down to which people are available. Many hospitals recruit one or more CDSs internally – either from their own HIS department or the clinical departments.

However you shouldn’t rule out advertising externally, considering that CDSs are a relatively new breed of professionals and hard to source.

Naturally, those who emerge from a coding environment will have a strong understanding of Diagnosis Related Groups (DRGs) and code requirements. Whilst those who come from a clinical background will have a deeper understanding of procedures, underlying morbidities, and clinical descriptions from doctors.

You may also select your CDS depending on the strengths and weaknesses of your departments.

For instance, your clinicians may be particularly good at supplying documentation to the HIS department yet may need additional guidance with meeting coding requirements. In this case, offering a Hospital Information Manager (HIM) a CDS position could be your best way forward.

Alternatively, if your clinical teams prefer to work with those from medical backgrounds or need a lot of assistance with the administration side of their work, you may consider a senior nurse, GP or similar. These professionals often develop a quick rapport with clinicians, as they can interact on the same level.

Another consideration may be whether your HIS department codes on pre or post-discharge. With pre-discharge coding, the CDS will need to work more closely with the clinicians. Whereas, with post-discharge coding, the CDS will need to focus on obtaining follow-up documentation and details.

Regardless of which persuasion you choose a prime element of the CDS role will be to interact well with both clinicians and coders and have a deep understanding of their needs.

A manager coaches a staff as they input data

Consider where the CDS should be embedded

The next consideration is where your CDS will be the most effective.

Most CDSs reside near the wards and clinicians. This facilitates easier access to medical professionals (and their wider teams) while they do their rounds etc.

Unless you are lucky enough to have multiple CDSs, you’ll also need to consider which medical department they should operate from. For instance, Obstetrics may have more coding complications than the Orthopedic department.

And if your CDS is operating as an extension of your coding team (and selected due to their coding background), they may be more efficient working closely to your HIS department.

Alternatively, you could choose a hybrid model where the CDS spends a set amount of time in different areas each week.


Developing culture is essential

As with all new procedures introduced to a hospital, it’s important to prepare your teams and facilitate good working relationships.

This may be in the shape of workshops, simple one-on-one introductions over coffee, or Toolbox Talk sheets distributed during team meetings.

The key messaging should be that the new CDI/CDS program will help clinicians and the HIS department substantially – saving them time, improving communications, minimising mistakes, and reducing confusion. Essentially, the CDS is there to make life easier for everyone and is very approachable.

We also recommend that you familiarise the CDS/CDS team with the leadership team to help maintain support of the project.


Ongoing monitoring and reporting

As discussed, the primary objective of implementing a CDI/CDS program is to obtain a first-time right approach to coding.

This, after all, was likely the primary sales pitch for funding the project – so keeping the leadership team abreast of financial and operational benefits will be important.

As CDI evolves (and it’s doing so rapidly) so too may your implementation of it – which will open doors for even more improved processes, cost savings and larger teams.


Getting help to get off the ground

If you need an outside perspective, there are a number of auditing and consulting services on the market to help point you in the right direction.

However, these groups won’t provide ongoing support as your CDI evolves – unless it’s at a fee. We believe that a more efficient use of money is to establish someone within the hospital to get the project off the ground.

To aid the process, we also recommend you invest in coding software that further enhances:

  • A first-time right approach
  • Education and feedback for users
  • Queries and coding management
  • Real-time data flow and a single source of truth – meaning no lag in updates for multiple users, historical accounts
  • Enhanced reporting and auditing tools
  • High level data protection
  • Ongoing support, training and upgrades as CDI processes evolve

Naturally, return on investment is paramount in establishing a business case for including software that supports your CDI/CDS program.

If you would like to see how Digital Agility’s Code Focus team can help ascertain your CDI/CDS requirements, and how the Code Focus software can economically support those requirements, we’d be delighted to talk to you. Effectively, we can set you on the long path to cost and operations efficiency. What’s more, we’ll support you throughout your entire CDI/CDS journey.

For a no-obligation demonstration of how Code Focus can answer your unique coding and auditing problems, contact Callum Haggerty at Data Agility.


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