No matter what the Centers for Medicare & Medicaid (CMS) decide to do with the ICD-10 implementation deadline, clinical documentation improvement (CDI) may become a survival tactic for hospitals.

CDI is a process typically used in hospitals that employs specialists who  review clinical documents and provide feedback to physicians, says Mark Morsch, vice president of technology at OptumInsight. The feedback is designed to fill gaps in documentation such as questions about coding, quality measures and overall care management of a patient. "This kind of  feedback loop back to the physician is intended essentially to make sure that documentation is high quality and corresponds to care delivered as well as the diagnoses that are being made."

The feedback loop could be a form that requests more information or a simple email that is sent to the physician. It can be labor intensive because it requires a CDI specialist who understands the clinical needs of patients and the gaps in documention in a chart.

Morsch says natural language processing (NLP) can streamline the process by identifying the important data elements. Run it across all the cases and present a prioritize list of cases to review.

But one of the problems with CDI is that it creates the feedback loop after a patient leaves the facility.

"We definitely see an opportunity and ability within technology to automate queries," says Morsch. That means an application could use NLP to recognize opportunities to provide better clinical information in real time - while the patient is there. "We want to be able to automate as much of that as possible to make that a very fast feedback loop."

That means a key part of this is linking the computer assisted coding (CAC) system to electronic health records (EHRs) and integrating into physician workflows. And not every query will be automated. Some diagnoses will be better suited to this technology.

Morsch says OptumInsight doesn't offer that capability now, but is working on it as part of their CAC products very soon.

Whether the feedback loop is automated or not, physician documentation training is an important part of the process. A CDI specialist can take a look at the types of queries and train physicians

"The big motivation here is of course ICD-10," says Morsch. The growth in codes and the increased specificity of the codes is going to require more detail in medical records. Hospitals will need specialist to make sure documentation leads to the correct ICD-10 codes.

But there are gains to be made now with documentation for ICD-9 coding. "Even without ICD-10, there is a very strong case for CDI," says Morsch.

1. Documentation supports coding which is the basis of correct revenue and reimbursement. Otherwise a hospital could be losing revenue.
2. Documentation is necessary for  complying with quality measures.
3. Quality information supports care management and making sure protocols are followed.

All three are good reasons to improve clinical documentation but it's the revenue considerations that create a real return on investment now and after ICD-10 implementation.