Tech & Innovation in Healthcare

Remember to protect patient data at all costs.

Clinical documentation improvement (CDI) is more than just changing the way healthcare providers write down the patient’s symptoms, what procedures were performed, or detailing the treatment plan. CDI is the process of ensuring complete and accurate medical documentation so providers can deliver optimal care and receive accurate reimbursement for their services.

CDI can be a time- and resource-intensive process but deploying artificial intelligence (AI) into CDI can help streamline the process.

Understand CDI’s Importance

“[CDI] is the process used by healthcare organizations to ensure that our provider documentation is accurately reflecting the care that is provided to our patients,” said Jacob Swartzwelder, CPC, CIC, CRC, CEMC, AAPC Approved Instructor, managing director of Compliant Approach Partners LLC, during his session, “Leveraging AI to Enhance the CDI Process,” at AAPC’s DOCUCON 2023.

Healthcare organizations see several different goals of implementing CDI, including:

• Accurate coding
• Accurate reimbursement
• Improve patient outcomes
• Improve provider communication

“CDI can have a lot of different goals. The goals of your CDI reviews or your CDI program need to be clear, and they can be prioritized. You can have primary, secondary, and tertiary goals,” Swartzwelder said. “We want to make sure that we have accurate and complete documentation, because it is essential for provider communication, revenue cycle, and patient safety,” he explained.

However, CDI is not always a quick and simple process. It can be a time-consuming and resource-intensive process that necessitates a lot of manual review. If your organization is short staffed, then you could face incomplete reviews or delayed reviews that could produce coding and reimbursement inaccuracies.

Luckily, technology is available to aid in your CDI process.

Analyze How AI Streamlines the CDI Process

Researchers and technology developers are constantly exploring AI’s potential in healthcare. “The biggest thing that I want to point out here is that this technology is advancing rapidly — especially in the healthcare space. We’re seeing things pop up; we’re seeing EMRs evolve, we’re seeing companies come in that have solutions involving AI or some sort of technology overlay, and it’s advancing incredibly rapidly,” Swartzwelder said.

AI has shown promise as beneficial to the revenue cycle, and with proper use, the technology can streamline your CDI process.

The areas where AI can help your practice’s CDI process include:

Documentation review: Sorts through large amounts of documentation and identifies areas that need reconsideration.

Real-time feedback: AI delivers real-time feedback to healthcare providers, which allows them to revise the documentation quickly to improve the quality. Empowers the physicians, nurses, and clinicians to make instant improvements for more accurate and complete documentation.

Identify under-documented conditions: Under-documented conditions are medical conditions that aren’t fully documented in the patient records. Without this crucial information, your medical coders will assign inaccurate codes and your practice could leave money on the table.

Boost coding accuracy: AI can flag possible coding errors, such as incomplete documentation or incorrect codes, so as to help ensure correct coding before the claim is submitted. The technology can also notify providers in real time of possible errors while they’re documenting the visit, so the providers can easily correct any mistakes.

Each of these areas ultimately help improve your workflow’s efficiency. When your practice has an efficient workflow, you’ll have optimized resources and staff that can improve the CDI process. Adding AI to your CDI process will save your practice time and help your providers craft accurate documentation for better patient outcomes, more accurate coding, and more timely reimbursement.

Beware the Caveats

AI is a rapidly evolving technology and with it comes plenty of caveats that practices need to be aware of before implementing it into their CDI process. The legal considerations of data privacy and security are the most important of all of those warnings. Using the technology to make your workflow more efficient is nice, but you should always prioritize protecting your patients’ information and complying with regulatory requirements.

Maintaining data privacy means complying with HIPAA, receiving patient consent for the AI system to access a patient’s data, and establishing rules for the gathering and storage of only the data that is necessary for CDI.

Safeguarding your patients’ data requires taking the necessary steps that you are required to with any technology. Enact robust encryption that protects data while it’s being transferred and stored. Use access controls to prevent unauthorized personnel and outsiders from gaining access to patient data. Perform security audits regularly to detect and address any security weaknesses.

In addition to legal considerations, you’ll want to examine any deployment hurdles prior to launching the technology. Make sure to do your due diligence to assess if your healthcare organization is prepared to handle AI in the CDI process. You can also consider creating a training plan for your providers, so they’re aware of what to expect once the technology is live.

Stay tuned to Tech & Innovation in Healthcare for more information as AI continues to evolve in healthcare.