I recently heard someone describe their EHR optimization as a Clinical Documentation Improvement (CDI) project. It made me start to wonder if CDI and EHR optimization were quickly becoming the same thing.
While some CDI programs require EHR optimization, not all CDI programs require it. Some EHR optimization can improve clinical documentation, but not all of them. However, there is a decent overlap between the two efforts.
There are a lot of ways a CDI program can improve your clinical documentation. As we start to see full adoption of EHR software, most of the CDI programs are going to focus on the way the visit is documented in the EHR. While the EHR use might be to blame in many cases, the most important part of any CDI effort is the people that use that program. In fact, it’s often not even about how they use the program, but just the choices they make.
What has become very valuable is that EHR’s have made CDI programs much more efficient. They can run the program remotely. They can run reports that focus on common clinical documentation errors and focus their program on those specific errors. Technology can really help a CDI program to focus on the pieces of the chart that matter most.
EHR optimization on the other hand could have nothing to do with improving the clinical documentation. It very well may be that the clinical documentation is perfect. In an EHR optimization, you may only be looking at how to improve the physician workflow while maintaining the high level of clinical documentation.
EHR optimization is a powerful thing and not enough organizations are doing it. I get that they’re too distracted by meaningful use, but if we’re going to really benefit from EHR software we need more organizations focused on optimizing their EHR use.
It will be interesting to see how hospital leadership handles the governance of CDI and EHR optimization programs. They are both going to be very important going forward.