ACDIS releases new position paper on CDI role in electronic health record implementation and compliance

Press Releases, November 5, 2014

The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position paper in its quarterly publication CDI Journal, October 1. The paper reflects the association advisory board’s recommendations for clinical documentation improvement (CDI) specialists’ involvement in electronic health record (EHR) implementation and ongoing record review for documentation accuracy and compliance concerns.

“We value the importance of incorporating technology into the workflow … but we also wanted to highlight some of the precautions that CDI professionals need to be aware of,” said ACDIS advisory board member Walter Houlihan, MBA, RHIA, CCS, HIM, and CDI director at Baystate Health in Springfield, Mass.

The position paper is the culmination of many months of discussion among the ACDIS advisory board, which meets regularly to discuss areas of national interest related to the CDI industry and to evaluate ways in which the association may appropriately respond to those challenges. In the paper, the advisory board addresses healthcare documentation concerns related to EHR meaningful use standards, copy and pasting clinical documentation from one day or one provider to another, electronically generated body mass index calculations, electronic physician query generation, and CDI staffing concerns among other items.

“We knew this [EHR implementation] was an important concern that needed to be addressed,” says advisory board member Dee Banet, RN, BSN, CCDS, director of CDI for Norton Healthcare in Louisville, Ky. “With EHR CDI programs are now charged with maintaining current progress while addressing all new challenges that come with the technology. We knew that we, as the ACDIS advisory board, needed to take a stand on some of these concerns.”
“I am proud of the work and the insight our advisory board members brought to this issue,” said ACDIS Director Brian Murphy. “Clearly, we have heard from our membership and from the healthcare industry at large that while EHR systems will no doubt help us better track and trend data and improve healthcare quality these systems are by no means a panacea to solve all physician documentation ills. We believe this position paper takes the first step in clarifying the expectations of CDI staff.”