Reinventing Clinical Documentation Integrity: Using Data to Move Mountains

Clinical documentation integrity programs have undergone a fundamental transformation in recent years. Once primarily used for billing and physician communication, clinical documentation has become a cornerstone for quality and even operational initiatives. At the boardroom level, large, far-reaching decisions on these issues are made based on rolled-up data that originates in individual patient records. This has created new opportunities for CDI teams, but also significant new pressures. Traditional CDI work such as improving documentation integrity for Medicare cases is worlds apart from complex quality work such as quantifying the risk of mortality across populations and payers. Likewise, for physicians, documenting the patient condition and disease state to enable reimbursement and effective continuity of care is fundamentally different from documenting patient encounters to enable calculations such as population-level risk adjustment. CDI programs are working to adapt and innovate in line with these system-critical demands. In this session, hear UC Davis’s groundbreaking approach to these challenges, and explore how they transformed their program from traditional CDI work primarily focused on appropriate reimbursement, to an analytics powerhouse that serves as a trusted source of data for the C-Suite to drive quality and performance improvement across the health system.