Report from AHIMA’s 2014 Clinical Documentation Improvement Summit

The following is an excerpt from the article “Leading the Documentation Journey: A Report from the AHIMA 2014 Clinical Documentation Improvement Summit,” published to the online research journal Perspectives in Health Information Management.

 

Excerpt

by Patty Buttner, RHIA, CCS; Angie Comfort, RHIT, CDIP, CCS; Jill Devrick, MPA; Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P; Deborah Kohn, RN, CDIP; Wil Lo, MD; Maria Ward, MEd, RHIT, CCS; Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, FAHIMA, CPEHR; and Anne Zender, MA

 

Abstract

The American Health Information Management Association (AHIMA) convened its annual Clinical Documentation Integrity (CDI) Summit in August 2014 in Washington, DC. The summit is committed to presenting interactive sessions, showcasing real-world examples, advancing networking opportunities, and providing critical insights to move CDI programs forward.

Current healthcare industry pressures demand change. AHIMA believes hospitals and providers, in all settings, must improve clinical documentation in preparation for the expanded scope of clinical data beyond a single patient encounter to a comprehensive data set across the continuum of care. The 2014 Summit took place in the aftermath of a Congressional action that delayed the implementation of ICD-10-CM/PCS code sets until October 2015. In recent months following the delay, AHIMA has heard conclusively that readiness and momentum towards the new code sets must continue and that CDI is an immediate opportunity.

Accurate clinical documentation is no longer a low-level priority for organizations today. It is a vital component to patient care, physician satisfaction, and revenue cycle strategies. CDI specialists, along with clinical care providers and senior management, must contribute to organizational success and ensure the right information is available at the right time. This paper presents findings and discussion from the 2014 summit and includes opportunities, challenges, and risks related to clinical documentation today. It also includes findings and AHIMA’s recommendations for actions to develop and maintain accurate and timely documentation.

 

Introduction

Since 1928, AHIMA has recognized that clinical data and information is a critical resource needed for efficacious healthcare. HIM professionals strive to ensure health information used in patient care is valid, accurate, complete, trustworthy, and timely. But current healthcare industry pressures are demanding change. AHIMA believes that hospitals and providers must improve clinical documentation in preparation for the expanded scope of clinical data beyond a single patient encounter to a comprehensive data set comprising the entire continuum of care.

AHIMA developed the CDI Summit to assist the industry lead the documentation journey and gain strategic advantage from implementing and maintaining accurate clinical documentation. This event provides a forum for thought leaders from all segments of the industry to engage in open discussion to better understand the perspectives of other stakeholder groups and develop opportunities to share best practices and lessons learned.

The goals of the 2014 CDI Summit were to:

  • Provide information to refine implementation strategies by leveraging opportunities and best practices
  • Move accurate documentation from a low-level priority to a strategic initiative
  • Demonstrate the connection between CDI and revenue cycle management, physician satisfaction, and patient care

 

Buttner, Patty et al. “Leading the Documentation Journey: A Report from the AHIMA 2014 Clinical Documentation Improvement Summit.” October 27, 2014. Perspectives in Health Information Management. http://perspectives.ahima.org/leading-the-documentation-journey-a-report-from-the-ahima-2014-clinical-documentation-improvement-summit/#.VE_gzWeCM40.

 

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