Moving to the Future of Clinical Documentation Improvement

Clinical documentation has come a long way since the days of paper medical records. Widespread adoption of EHR systems and now EHR optimizations have modernized the act of clinical documentation, and much to the benefit of the healthcare revenue cycle. However, there is still much to do with clinical documentation improvement (CDI) as Michigan Medicine has found out.

The EHR system has benefited the healthcare industry, but it has also created other challenges for providers, according to Benjie Johnson, chief revenue officer at the academic medical center. For example, Johnson has heard from providers about the number of clicks it takes for a provider to complete charge capture.

Research has directly linked clinical documentation to clinician burnout. But the act of documenting clinical cases in the EHR is still a very necessary task and one that has become increasingly tied to the healthcare revenue cycle. Accurate, quick reimbursement relies on not only charge capture, but also accurate documentation of hierarchical condition categories (HCCs) and other clinical information for payment systems using methods like diagnostic-related groups (DRGs) and value-based payment.

“Documentation is the key piece both for patient care and for revenue—that’s where we really came up with, ‘How do we make it easier to create documentation?’ Because if it’s easier to create documentation and edit documentation, then that will get us what we need from a revenue cycle perspective,” Johnson recently told RevCycleIntelligence.

That line of thinking launched a CDI transformation project at Michigan Medicine and one that not even COVID-19 could stop.

“COVID hurt us financially and we had to implement an economic recovery plan that included FTE reduction. We paused major projects including facility and IT improvements. But in the midst of all that, leadership decided to move forward with the CDI project. That’s how important it was,” Johnson stressed.

Johnson and the project team knew that clinical documentation needed to become more efficient and convenient for providers in order for both patient care and revenue to benefit. But the question was how to get to that point.

“We needed a vision,” Johnson explained. “One of the things, in talking to our IT partners, is what they saw coming down the road, which is ambient technology. That whole premise of walking into a room and you start talking to the patient and that information gets captured as opposed to a physician typing it in or dictating it in after the fact.”


Ambient computing is a form of artificial intelligence that is sensitive, adaptive, and responsive to human behaviors and needs. The technology has notably been leveraged in smart hospitals through sensor-based solutions. However, adoption is just starting to take off for this type of technology, especially in the revenue cycle.

“It is definitely a futuristic goal that’s not here just yet, but it seemed to make sense to partner with a technology vendor that has the same sort of roadmap, the same sort of vision, and has the capability of getting there,” Johnson stated.

Michigan Medicine’s revenue cycle has generally relied on a best-in-breed vendor strategy when it comes to implementing new technology to streamline processes. But that strategy did not support the forward-looking vision the medical center has now adopted in the revenue cycle.

“We decided that we need to be more thoughtful about the future than just reacting and saying, ‘Hey, our contract is going to be up. Do we renew? Do we do an RFP? How do we improve on what we’re doing?’ We viewed this project as a way to change how we view our vendors to more of a strategic partnership and shifting away from best of breed,” Johnson said.

Michigan Medicine recently pared down the number of vendors it is working with for CDI and auditing to one: 3M Health Information Systems. The medical center implemented a full portfolio of technology to start on the path to ambient clinical documentation.

Among the technologies Michigan Medicine implemented earlier this year is a coding and CDI workflow tool and front-end speech recognition. Later, the medical center is planning to implement computer-assisted physician documentation (CAPD) and computer-assisted coding (CAC), as well as an HCC workflow.


Technology is certainly the future of coding and CDI. However, technology is only as good as its users and the only way to leverage ambient computing for CDI is to make it easy to use for providers.

“Our second step is to start to have the discussion around CDI, both on the outpatient and inpatient side, although we’ve had it in inpatient for a long time,” Johnson said. “Do we use the 3M technology to prompt documentation or initially create documentation for editing? Do we use data to tell us where we need to focus to improve HCC capture and RAF scores?”

The CDI transformation team is starting to answer these questions and with the provider in mind. For context, Michigan Medicine is the largest hospital in the state and also part of a larger health system.

“We have 3,500 providers with the full spectrum of clinicians who are computer facile and those who are not.” Johnson explained. “You have to take small steps in preparation for something like ambient technology. If they become comfortable with front-end speech and computer-assisted documentation, integrated with the EHR, it is our hope that the transition to ambient is not so daunting.”

Johnson’s team is actively working on completing this step by increasing usage of technology solutions implemented as part of the medical center’s new vendor strategy. Specifically, Johnson believes increased usage of front-end speech understanding, computer-assisted physician documentation, and virtual assistant solutions can bring the entire organization one step closer to its goals of ambient computing-powered clinical documentation.

Michigan Medicine has already seen a significant uptick in staff using the new technology thanks to an organization-wide effort to switch users from the legacy system.

“Another thing that’s interesting that we found out is the technology had specific microphones or devices that they used, but then some people returned them and said, ‘Hey, my phone works just fine with it.’ So less devices. Again, trying to use what we have but make it simpler for the provider,” Johnson added.

Getting providers on board with new technology and workflows is, after all, how to get the entire organization into the future of CDI. Clinical documentation and charge capture depends on the actions of many people within a healthcare organization, from clinical to administrative departments. As these processes evolve, everyone will need to be on the same page to make clinical documentation transformation a success.

Author : Jacqueline LaPointe