How to Consistently Provide and Corroborate Effective Clinical Documentation Integrity

Effective clinical documentation integrity (CDI) plays a critical role in healthcare. It supports positive outcomes for patients, emphasizes high-quality data generally, and leads to a more efficient reimbursement process for claims. 

Let’s take a closer look at clinical document integrity in healthcare, starting by briefly defining the term itself.

What is Clinical Documentation Integrity?

CDI, also called clinical document improvement and clinical document integrity and compliance, refers to efforts to improve patient medical records. The American Academy of Professional Coders calls CDI “the process of reviewing medical record documentation for completeness and accuracy.”

On a foundational level, CDI helps hospitals, health systems, and other providers maintain accurate records. In turn, that leads to a wide range of benefits for all stakeholders. Advantages that stem from improving clinical data integrity through EHR documentation include less friction in the claims process and more informed clinicians. 

An effective CDI program, including clinical documentation integrity software, can also help address reporting and compliance needs. Ensuring data is correct, complete, and current is incredibly valuable. It offers tremendous support during an audit and when generating and reviewing internal metrics and reporting.  

Translating information into accurate diagnosis codes is also a key component of CDI. Clinical documentation and coding integrity supports a more accurate medical record for patients, providers, and payers alike. 

How Do Providers Manage Needs Related to CDI?

Skilled professionals take on CDI specialist positions that focus on this key area of healthcare operations. These specialists determine the completeness and accuracy of clinical documentation. At the same time, they review the suitability and appropriateness of medical codes included in those records.

How XSOLIS Supports Effective Documentation Integrity

CORTEX®, our AI and analytics-driven solution for utilization management, uses Natural Language Processing (NLP) to extract valuable insights from unstructured data. In other words, it reviews written notes and clinical commentary and pulls the most useful narrative information about a patient from them. 

That’s clearly a valuable process for patients and clinicians. It supplies nurses, Physician Advisors, and other staff with additional, contextually useful information that supports effective treatment. CORTEX doesn’t stop at extracting this narrative data, however. It also has the power to compare this data to similar cases. 

That means CORTEX can offer providers additional insights and predictions related to patient status and more. It will even notify UM teams when its recommended patient status doesn’t align with a patient’s actual, assigned status. 

Crucially, CORTEX can share this information beyond UM clinicians and the medical staff. It provides easily understandable and relevant information to payers in real time. That puts everyone on the same page and reduces the need for frustrating, time-consuming emails, phone calls, and faxes.  

With a single set of accurate and current data, it’s far easier to build a collaborative relationship with payers. 

For MultiCare Health System in Washington, digital transformation of their utilization management team began by partnering with XSOLIS’ award-winning Physician Advisory (PA) Services. Their specialized view of CORTEX created more efficiency and improved payer relations, making XSOLIS a “valuable, reliable and trusted partner,” according to MultiCare’s Debbie Schardt. CORTEX makes the unstructured data in patient medical records more immediately accessible, supporting more effective clinical documentation integrity.  

Learn more today about how XSOLIS PA Services can support your hospital or health system.