CDI - Clinical Documentation Improvement
“Ground zero” for many significant healthcare initiatives is found in clinical documentation. Providers are automating the capture of ever increasing amounts of clinical and quality documentation – while at the same time physicians and other care providers feel they have less time to document, and HIM leaders wrestle with ICD-10, EHR, RAC, POA, and other demands. All are highly dependent on the quality, integrity and reliability of clinical documentation.
And while the strategic importance of Clinical Documentation Improvement is obvious, the bar is rising to also capture expanded Quality measures like NCQA, Hedis and other core measures – all as a byproduct of documenting during care delivery.
Jacobus Consulting provides Clinical Documentation Improvement services tailored to the level of need of the individual healthcare facility. Our Clinical Documentation Improvement (CDI) education, tools and training assist the healthcare facility to positively impact the quality, timeliness, and completeness of physician and clinician documentation in the healthcare record. There are hundreds of daily processes that contribute to clinical documentation and the solutions for improvement must bring together solid methodologies for process redesign and best practice education programs.
The Jacobus CDI methodology builds the foundational elements that support your patient quality and safety initiatives and utilizes proven process redesign disciplines to ensure consistent care delivery and documentation across the continuum. Our team consists of expert Physicians in Quality Patient Care and Informatics, Health Information Management Professionals, Quality Performance and Innovation Professionals, Clinical Informatics Professional, Electronic Health Records Implementation Specialists, and Revenue Cycle Expertise.
The Jacobus Approach to CDI:
Our approach is based on strategic teaming with your personnel for a more cost efficient CDI solution, and to build CDI as a core competency in your organization. Jacobus has successfully delivered CDI programs that address the four key CDI requirements - typically found in 2 stages of implementation:
- Initial Retrospective Review - often practical for providers who have not yet implemented documentation improvement program, and
- Point of Service Documentation Review - while the patient is still in the hospital.
This latter stage more firmly establishes the structures created in phase 1 for ongoing provider education, monitoring and oversight and will drive continual documentation improvement.
Jacobus CDI Programs are tailored for a health system’s specific situation and are designed to gain support of physicians and other care providers. The program may be expanded to address clinics, employed and non employed physicians, and improved coding and billing. Our CDI Programs provide the education and tools that meet expanded documentation scope and standards demanded by ICD-10 CM/PCS.
Jacobus CDI Program Services Include:
- CDI Assessment - Initial analysis of coded medical record data to identify needs for documentation improvement. The analysis also identifies other issues such as preadmission review, denials management, case management and use of observation services.
- CDI Re-Assessment - Outside review of an existing in-house, or 3rd party CDI program to identify what is working well, as well as suggestions for enhancement with a view toward ICD-10. This can include planning for expansion to encompass physician provider services.
- CDI Program Implementation – Implementation of a complete, facility specific CDI Program.
- Advanced Clinical and EMR HCIS System Enhancements and Audit – including system screen and query modifications and enhancements to data structures for compliance with ICD-10 requirements. Audit includes analysis of current EMR implementations for Meaningful Use compliance, Legal Record compliance, ability to support multiple clinicians and “tell the patient story”, support for Quality data requirements, HCIS system usability.
- Clinical Documentation Specialist Education and Shadowing - A comprehensive CDS education program with on-unit real time education.
- Physician Specialty Specific CDI Training – Ongoing training and everyday tools to assist physicians with ICD-10 CM and ICD-10 PCS specific documentation requirements.
