The future of clinical documentation improvement (CDI) will require expanding the reach of CDI programs into new areas of expertise because the traditional realms of CDI work are increasingly becoming automated. CDI-based research and analytics can serve as a means for demonstrating continued value to an institution. We present four studies as examples of these efforts.
Clinical coding constitutes one of the fundamental functions in the field of health information management. Clinical classification systems and clinical terminologies represent two distinct sets of coding schemes that are used in healthcare. In this context, it is critical to distinguish between clinical terminologies and clinical classification systems, identify how both sets of systems are utilized in healthcare settings, and acknowledge individual contributions of each system to providing data infrastructure for clinical as well as administrative data uses in the healthcare delivery system.
Secondary use of large and open data sets provides researchers with an opportunity to address high-impact questions that would otherwise be prohibitively expensive and time consuming to study. Despite the availability of data, generating hypotheses from huge data sets is often challenging, and the lack of complex analysis of data might lead to weak hypotheses. To overcome these issues and to assist researchers in building hypotheses from raw data, we are working on a visual and analytical platform called PRD Pivot.
Health information management (HIM) professionals’ involvement with disease classification and nomenclature in the United States can be traced back to the early 20th century. In 1914, Grace Whiting Myers, the founder of the association known today as the American Health Information Management Association (AHIMA),
A descriptive study of health information technology (HIT) vendors was conducted to identify which EMR/EHR vendors currently work or anticipate working with SNOMED CT, determine the prevalence of SNOMED CT integration in electronic medical record (EMR) and electronic health record (EHR) products, identify the available and potential future applications for SNOMED CT in EMR/EHR systems
The International Classification of Functioning, Disability and Health (ICF) is a component essential to ensuring the collection of accurate and complete healthcare data that correctly reflect the care provided to individuals. In fact, many countries outside of the United States have found uses for ICF.
