CDI Specialists Can Ease Documentation Burdens in the Workplace and in Washington

Clinical documentation improvement (CDI) specialists, undeniably, make a difference every day in their facilities by ensuring that a patient’s care is expertly reflected in their chart. But CDI professionals can extend their influence even further by advocating for their facilities and patients at the state and federal legislative and regulatory levels, according to Lauren Riplinger, JD, vice president, policy and government affairs, at AHIMA.

Lauren Riplinger, JD, vice president, policy and government affairs, at AHIMA and (right) Casi Birnbaum, MS, RHIA, CPHQ, FAHIMA, HIM and revenue integrity, UC San Diego Health.

“As health information management (HIM) professionals, you have a unique opportunity to share your expertise, advocate on behalf of the profession as well as the patient, and educate lawmakers,” Riplinger said during the second keynote presentation, “Connecting the Medical Field with Politics and Advocacy,” at AHIMA’s CDI Summit.

Regulatory Efforts Target Documentation Burden

The 21st Century Cures Act, which was passed in 2016, launched a series of rulemaking actions which targeted—among many other technology-focused healthcare initiatives—the physician crusade against administrative burdens. The Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS) identified six stakeholder priority areas to address under the Cures Act, which tie directly to the jobs of HIM professionals and CDI specialists:

  1. Billing related documentation (aka “note bloat”)
  2. Prior authorization
  3. Quality measurement
  4. User experience with health IT and clinical workflows
  5. Excessive time spent outside of patient care on electronic health records (EHRs)
  6. Prescription drug monitoring programs (PDMPs) poorly integrated into EHRs

To effectively address these issues, CMS and ONC’s joint strategies require feedback from HIM professionals and a successful, efficient implementation relies on their cooperation. Riplinger detailed AHIMA’s advocacy efforts on this front, including comments submitted in June to ONC for the 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program proposed rule.

Riplinger also noted that CMS is currently accepting stakeholder feedback on its “Patients Over Paperwork” initiative. CMS announced a request for feedback (RFI) in June for strategies to further reduce administrative burdens. AHIMA will be submitting comments as well, and Riplinger encouraged members to send feedback to AHIMA by July 31. Comments can be sent to [email protected].

Mary Butler is associate editor at Journal of AHIMA.

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