HI 150 Purdue University Week 4 Clinical Documentation Improvement Paper

Notes:

For the clinic selected, consider the information needs for the customer. Distinguish the Clinical Documentation Improvement (CDI) software needs that would be seen within the clinic from the CDI needs across the healthcare continuum.

For the clinic selected and the Clinical Documentation Improvement (CDI) software selected, apply your knowledge of database architecture and design for the clinic’s needs.

Please include a brief explanations on the needs of data dictionaries, data warehousing, and overall database architecture (OLAP v. OLTP). Include a listing of the database items that would need to be gathered, their definitions, and how they are utilized.

Instructions:

Assume you are an Office Manager for a small to medium size physician practice clinic. Review the Readings from Unit 3 and Unit 4 including the information on Systems Selection, Implementation, and the Appendix A RFI/RFP reporting format in addition to the discussion boards and seminar presentations for Units 3 and 4. I have attached both Seminar powerpoints in the attachments folder. Here is the book link The login info will be attached as well.

Deliverable: Prepare a 3-4-page report that outlines:

  1. The needs of the clinic as it relates to Clinical Documentation Improvement Software including:
    • What is Clinical Documentation Improvement?
    • What, if any, barriers exist to implementing the software?
    • What is the role of the HIM professional?
  2. The needs of the larger healthcare community/continuum as it relates to Clinical Documentation Improvement Software.
  3. Research at least three Clinical Documentation Improvement software vendors and review their systems. At a minimum, include the following information in comparing the vendors in a table format:
    • What are the benefits of the system as listed on their web page?
    • What kind of facility utilizes the vendor’s system?
    • Is there a coding encoder system component part of the system or available?
    • Are there any advantages of their system over others (as listed on their web page)?
    • Any information available in prices, demonstrations, free trials, and implementation. Could you “see” inside the system on the vendor’s web site?
    • Conclude your review with a statement of which system you would purchase as a small office physician practice and why?
  4. In your table or in an additional table, outline the database dictionary terms and definitions commonly used in the implementation of Clinical Documentation Improvement software in a Health Information Department.
    • What items should be included in the reporting database according to the needs of the clinic as well as the broader health information community/continuum of care?
    • Are their multiple definitions available for singular terms?

Assignment Requirements

  • Prepare a 3-4-page report that follows the conventions of Standard American English (correct grammar, punctuation, etc.) addressing the above questions and issues and in a Microsoft Word document, where appropriate.
  • Include your table comparing the CDI vendors and data dictionary items as either a standalone document or embedded in the Word Document.
  • The body of your document should be at least 1000 words in length.
  • Quoting should be less than 10% of the entire paper. Paraphrasing is necessary.
  • Students must cite and reference at least 4 credible sources from the University Library.
  • Your writing should be well ordered, logical and unified, as well as original and insightful.
  • Your table(s) (see example below) may be created in Word, PowerPoint, or Excel.

Be sure to visit APA Central to assist you with meeting APA expectations for written Assignments.

Your work should display superior content, organization, style, and mechanics. Furthermore, all sources used should be properly cited using APA.

Expert Solution Preview

Introduction:
This report aims to provide information on Clinical Documentation Improvement (CDI) software needs for a small to medium-sized physician practice clinic. The report will discuss the clinic’s needs regarding CDI, the role of HIM professionals, and barriers to implementing the software. Furthermore, the report will explore the needs of the broader healthcare community and compare at least three CDI software vendors. Additionally, a database dictionary terms and definitions commonly used in the implementation of CDI software in a Health Information Department will be outlined.

1. What is Clinical Documentation Improvement?
Clinical Documentation Improvement (CDI) is a process that healthcare organizations use to enhance the quality and accuracy of patient documentation. The primary goal is to ensure that medical records are comprehensive, accurate, and reflect the patient’s clinical status accurately. CDI software helps healthcare organizations optimize their reimbursement and ensure compliance with regulatory requirements.

2. What, if any, barriers exist to implementing the software?
One of the main barriers to implementing CDI software is the cost involved in acquiring and implementing the technology. Organizations also experience a significant learning curve as they adopt new software systems. Additionally, integrating the CDI software with other technology platforms within the clinic can also present significant challenges.

3. What is the role of the HIM professional?
Health Information Management (HIM) professionals play a vital role in CDI software implementation as they have a deep understanding of medical terminologies and coding systems. In a CDI software implementation project, HIM professionals would be responsible for ensuring the electronic medical record is accurately capturing diagnoses, procedures, and care provided to patients. HIM professionals would also work closely with medical staff to ensure the documentation reflects the patient’s condition accurately.

4. The needs of the larger healthcare community/continuum as it relates to Clinical Documentation Improvement Software.
The broader healthcare community needs CDI software to ensure patient safety and quality care. CDI software has become increasingly important with the transition from fee-for-service to a value-based reimbursement model. CDI software helps healthcare providers to optimize their reimbursement and reduce the risk of denied claims, which can significantly impact a healthcare facility’s financial health.

5. Research at least three Clinical Documentation Improvement software vendors and review their systems.
Three CDI software vendors that can assist a small physician practice are 3M, eClinicalWorks, and M*Modal.
The table below compares these vendors based on the following criteria:

| Vendor | Benefits | Type of Facility | Coding Encoder | Advantages | Prices/Demos/Free Trials | Which system to purchase |
| — | — | — | — | — | — | — |
| 3M | Improve Accuracy and Reimbursement | Outpatient and Inpatient Facilities | Yes | Multiple modules available | No pricing information on the website | 3M |
| eClinicalWorks | Streamline Documentation | Outpatient Facilities | Yes | Cloud-based platform | Free demos and pricing information available | eClinicalWorks |
| M*Modal | Improve Physician Documentation | Outpatient Facilities | Yes | AI-powered Technology | Pricing information not readily available | M*Modal |

6. In your table or in an additional table, outline the database dictionary terms and definitions commonly used in the implementation of Clinical Documentation Improvement software in a Health Information Department.
The following items should be included in the reporting database, as they are crucial for clinical documentation improvement software implementation in Health Information Department:

| Item | Definition | Utilization |
| — | — | — |
| Diagnosis | A medical condition | Used to identify the reason for the patient’s medical visit or condition during admission |
| Procedure | Any medical treatment performed on a patient | Used to document the medical care provided to the patient |
| Clinical indicators | Documentation that describes the patient’s current condition | Used to ensure that the medical record is an accurate reflection of the patient’s clinical status |
| Coding guidelines | Standards that dictate the assignment of codes to medical diagnoses and procedures | Used to ensure that coding is accurate and consistent |

Conclusion:
In conclusion, CDI software is essential in today’s healthcare industry to ensure that medical records accurately reflect the patient’s clinical status. The costs of implementing CDI software can present significant barriers to healthcare facilities’ adoption, but the benefits outweigh the challenges. In selecting a CDI vendor, a small to medium-sized physician practice must evaluate the vendors’ pricing and features closely. A Health Information Department will require various database items such as diagnoses, procedures, clinical indicators, and coding guidelines to implement CDI software effectively. HIM professionals have a crucial role to play in the implementation and operations of CDI software.

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