Emerging Technologies for Clinical Documentation Improvement

AUGUST 12, 2010
Jonathan L. Elion MD, FACC
The Photographic Painting
Often the value of a new technology is not understood for many years after its invention.  The first film cameras were initially used to capture “photographic paintings” of landscapes, still life studies and portraits, the standard subject matter for artists using traditional media.  It wasn’t until much later that the technology began to realize its full potential in fields as diverse as astronomy, microscopy and movies.

Computer applications in the Clinical Documentation Improvement (CDI) field are poised to make a similar transformative leap.  Rather than simply recreating what we already do today with notes and spreadsheets, emerging and converging advances will allow for totally new workflows, efficiencies, integration, reporting and analysis.  Some of these recent trends will have a tremendous impact on CDI programs.

Rules-based Expert Systems
An expert system is a specialized type of software that provides answers to problems, eliminating the need to consult a human expert.  In a CDI program, by collecting clinical information, examining its own knowledge base and applying rules, and Expert System can makes it documentation expertise widely available throughout a hospital.  While medical expert systems have been around since the early 1970s, this form of artificial intelligence has not found a significant place in commercial medical products due to the difficulties in developing and maintaining the medical content of knowledge and rules.  Traditionally, the human expert needed to work side-by-side with a computer engineer to program the rules.  Today, novel approaches to the design of content management tools now means that the human content expert can develop the knowledge base without an understanding of the programming.

The expert system approach has already been shown to be capable of providing a number of enhancements to a CDI program, where its rules are applied to the clinical data that has been collected.  For instance,
  • By examining the list of a patient’s medications and laboratory results, the expert system can suggest additional diagnoses.  This can be as simple as a reminder to add the diagnosis of “anemia” when hemoglobin or hematocrit are low, or could include more complex inferences and interactions.
  • By identifying simple relationships among diagnoses, the expert system can make suggestions such as “acute systolic heart failure” when there is “volume overload.”
  • By putting together more abstract diagnoses such as gastrointestinal bleeding and a low hemoglobin and hematocrit, the expert system could suggest the user consider anemia, and then query for acute post-hemorrhagic anemia.
  • While an expert system cannot be expected to be betterthan the human expert, the system provides the ability to automate and clonethe expertise.  This becomes extremely helpful in improving efficiencies and in training new staff in the subtleties of CDI.

Hosted Data Centers
Providing such an expert system requires that the “knowledge”, or software system, be made available throughout the organization, a goal that is easily accomplished with the use of a hosted data model.

In the past, the use of “software as a service” and “application service provider” approaches were met with concerns over security and confidentiality, causing many hospitals to return to a strategy of owning and maintaining their own software and hardware.  However, advances have made this “hosted data center” approach attractive once again, offering not only greater security, but economies of scale and reduced operations and maintenance costs.  The technology that underlies a hosted data center ensures that all users have continual access, and secure patient data, and allows for the aggregation of data, which can be used for benchmarking and comparisons with peer groups.  Perhaps the most significant impact of this approach is the elimination of the barrier to entry, by requiring no hardware or software installations, and permitting new customers to be brought online in a matter of hours instead of weeks or months.  For the small hospital, this means access to sophisticated computer systems without the need for a similarly sophisticated IT department.  For the large hospital, the burden of managing software licenses and installations is eliminated. 

Similarly, a web-delivered product can avoid the problems created by rogue programs and viruses on a hospital’s personal computers.  Until recently, most applications required the installation of software onto the desktop, which opened the door to malware and made hospital IT departments wary.  Today’s advances have eliminated that need, allowing immediate and secure access to data over the web from any browser, and ensuring that all users are running the most current version.

Business Intelligence
The utilization of an electronic CDI program enables data to be grouped, analyzed and presented to the user in a way that isn’t possible with paper-based systems.  Moving far beyond providing the user with a list of work to be done that day, an electronic system can provide reporting layers that start with a summary snapshot and drill-down to details and metrics.   This can include query response rates, case mix index changes, revenue impact and compliance, both within the individual hospital and across the peer group.  Most importantly, it not only monitors the efficiency of the current CDI program, but also can provide insight into improvement efforts still left to be achieved.

Electronic Documentation Means Better Documentation
With any CDI program, the end result is better documentation.  An electronic CDI program that utilizes an expert system will help ensure that proper information has been captured to support an audit.  More complete documentation can be captured at the onset; AHIMA-compliant queries are standardized and their results captured and retained; audit tools show compliance between CDI and coders; and documentation is read on demand, whenever it is needed.

The Future Is Near
The combination of knowledge-based expert systems and electronic delivery methods stand to transform CDI efforts from paper-intensive programs, into powerful and easy-to-use documentation systems.  These can ultimately be integrated into a hospital’s information system, making the expert system even “smarter” as it captures medication, procedure and lab data, and begins gathering diagnostic suggestions and query proposals even before the user logs on.  Just as the original film camera found a purpose far beyond landscape photography, emerging and converging technologies are being applied to purposes beyond their original intent, and will revolutionize healthcare documentation.


Dr. Elion is an Associate Professor of Medicine at Brown University and a practicing cardiologist at The Miriam Hospital in Providence, RI. He is the founder of ChartWise Medical Systems, Inc. in Wakefield, RI, a medical software firm whose rules-based expert system assists physicians and Clinical Documentation Specialists with increased efficiencies and completeness of documentation, queries and workflow.  He is a graduate of Brown University (BA and MD), trained in Internal Medicine at the University of Wisconsin, and in Cardiology at Duke University.  Contact him at 401/473-2003 or by email at jElion@ChartWiseMed.com.


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