As the demand for accurate and timely clinical documentation increases, health information management (HIM) professionals are using their skills and expertise to improve documentation. Because clinical documentation is at the core of every patient encounter, in order to be meaningful it must be accurate, timely, and reflect the scope of services provided. Successful CDI programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality report cards, physician report cards, reimbursement, public health data, and disease tracking and trending. HIM professionals provide two key roles within a CDI program as a clinical documentation improvement specialist and coding professional. By working together, HIM professionals can support their organizations efforts to collect and provide meaningful information throughout the continuum of care.

HIM professionals advocate for a strong commitment to accurate and timely clinical documentation as industry initiatives push forward with programs such as ICD-10-CM/PCS implementation, Accountable Care Organizations reimbursement models, Fraud and Abuse compliance programs, and implementation of electronic health records (EHRs).

HIM professionals also impact CDI programs by providing education regarding compliant documentation to physicians, something that is not taught in medical school. Organizations must compensate for this lack of training by instituting CDI programs that align with good documentation habits. HIM professionals, through their education, are familiar with compliant documentation rules and regulations as well as accreditation standards that affect timely documentation. In addition, HIM professionals are also familiar with important areas such as privacy, security, and confidentiality that also impact sharing of clinical information.

Health information management (HIM) roles are evolving as the industry moves forward with a variety of initiatives, including implementation of an electronic health record.  As the health record evolves into a complete and accurate picture of the patient’s treatment, including information from personal health records and health information exchange the need for advanced information management skills are needed. 

Organizations depend on HIM professionals’ skill set.  The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more importantly to a healthy patient.  To that end, CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.

A CDI program includes a myriad of people, processes, and technology that must work together to ensure success.  Organizations need a well rounded individual who can articulate effectively all of the pieces, documentation requirements, code assignment, coding guidelines, and quality reporting.

In response to this changing environment, CDI Specialists must improve work processes, communicate with clinical providers and redesign clinical documentation improvement practices.  CDI Specialists must continue to learn and develop new skills and move forward with regulatory changes.

HIM professionals hold diverse roles within the revenue cycle for their organizations and physician practices such as CDI Specialists, CDI Managers, Coding Professionals, and Revenue Cycle Auditor.