practice guidelines for managing health information
THE PROVERBIAL COMPARISON of “apples and oranges” is
a well-known metaphor in casual conversation and discussion. When talking about expanding clinical documentation
improvement (CDI) programs in today’s environment of electronic health records (EHRs) and information governance
efforts, the scope extends beyond the walls of the hospital to
other areas, such as physician practices. In the apples and oranges scenario, these two types of documentation (inpatient
and outpatient) are an apt comparison. Just as it’s all documentation no matter the healthcare setting (and apples and
oranges are both fruit, in the end), they also have their differences. But are they really all that different? Herein lies the
challenge—bringing the two together requires that the inpatient CDI program be put in the same “fruit bowl” as the outpatient CDI program.
Why would a healthcare organization want to develop an outpatient CDI program in the first place? If an organization already
has an inpatient program, it may be beneficial to tie in outpatient reviews. As providers discover and acknowledge benefits
of inpatient CDI programs, they may begin to look toward defining an outpatient CDI program’s benefits. One of these benefits
includes better coding accuracy, which in turn would benefit
more accurate diagnoses populating the patient problem list
and then pulling the information into subsequent notes, so it
could be coded and available for continuity of care. The result is
better quality documentation and care for the patient.
The Centers for Medicare and Medicaid Services’ (CMS’)
value-based reimbursement programs are bringing the apples
and oranges together. As accountable care organizations are
developed, consideration for bringing information from inpa-
tient and outpatient encounters together makes for a sensible
endeavor. EHR systems and patient portals may lend a wider
view of patient encounters. One portal for both the outpatient
office and the hospital may be available. Once a patient is as-
signed their patient portal, the problem list flows into the por-
tal from interoperable inpatient, outpatient, and ancillary in-
formation systems and the patient can then see the complete,
accurate, real-time documentation of their conditions. There
are numerous ways CDI can impact the clinical specificity of
these shared records, and the problem list is just one example.
CDI programs bring those apples and oranges together and
adapt the clinical documentation and diagnosis-related group
(DRG) assignments based upon the documentation and diag-
noses from the outpatient office notes and the hospital notes.
As healthcare shifts toward a system tied to quality of care
practice and greater interoperability, it becomes increasingly
necessary to ensure organizations’ health information technology (HIT) infrastructure and CDI programs are up to the
undertaking. An essential element to this is expanding the role
of a CDI program and ensuring that key standards are met.
Standards and Standards-based Services for CDI
Standards enable the health IT infrastructure, which in turn
allows various information systems to interoperate, communicating information broadly and overcoming distance, differing levels of expertise, location of delivery, and other barriers.
Healthcare service delivery can cross physical walls of organizations, and can occur safely with accurate reimbursement and
the appropriately applied support of both health IT and health
information management (HIM) practice standards. These
standards provide consistent, reliable, and trusted communication between patients and those involved in their care. The
standards apply to all facets of healthcare delivery, delineating
content and creating basic definitions on the required content.
Data standards and information content standards are important in this regard. 1, 2
Vocabulary, terminology, and classification system standards
allow uniformity with clinical content communication. The
International Statistical Classification of Diseases and Related
Health Problems, 10th Revision, Clinical Modification (ICD-
10-CM) and Procedure Coding System (ICD-10-PCS) and the
Current Procedural Terminology (CPT) are the key standards
for translation of human language in clinical documentation
into machine-processable payload for health management,
epidemiologic efforts, and reimbursement. Diagnoses, procedures, diagnostic testing, and other services delivered can be
uniformly communicated due to the use of these standards. For
example, ICD-10-CM/PCS classifies diseases and health problems, while CPT translates delivered services in a uniform manner nationally and internationally.
The Systematized Nomenclature of Medicine–Clinical Terms
(SNOMED CT) is a comprehensive multilingual clinical healthcare terminology with scientifically validated clinical content
that enables consistent, processable representation of clinical
CDI Expanding Beyond the Hospital Walls