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Background <p>Despite growing understanding, integration of Clinical Documentation Integrity (CDI) into the clinical environment is challenged by complex physician workflow, perceptions of time, and attitudes towards the electronic medical record (EMR). New innovations such as computer assisted coding and AI-software have shown improved efficiency for CDI specialists and coders. However, more understanding about the impact on documenting clinicians is needed.</p> Methods <p>A CDI software with expanded options for query review through EMR, web-based, and mobile application platforms was integrated. Hospital Medicine physicians were surveyed about query platform usage, platform workflow integration, query template clarity, and overall perception of integration changes. CDI query metrics including (1) total query number, (2) response percentage, (3) confirmation percentage, and (4) response time were compared between resident and non-resident groups for 6&#xa0;months pre- and post-software integration.</p> Results <p>Post-intervention surveys were completed by 56 of 116 (48%) resident and 61 of 108 (56%) attending physicians. Mobile application platform use was highest among both resident (86%) and attending (89%) physicians. All platforms were reported as effective in clinical workflow integration. New templates improved ease of locating and understanding the query. Post-intervention, an increase in overall query volume was noted. However, average query response time, completion rates and confirmation rates all improved on both resident and non-resident groups. Overall, the software integration was reported as a positive change.</p> Conclusions <p>CDI integration into the unpredictable clinical environment can be successful when innovations promote flexibility for physicians with varied clinical and documentation experience.</p>

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Impact of clinical documentation integrity query software into hospital medicine workflow: a comparison of resident and non-resident teams

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年8月1日

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  • Michael Rouse,
  • Matthew Jones,
  • Archana Pareek,
  • Cheryl A. Gibson,
  • Rebekah May,
  • Tanya Ekilah,
  • Matthew Struempler,
  • Brittany Chambers,
  • Dave Soni,
  • Brice Zogleman

摘要

Background

Despite growing understanding, integration of Clinical Documentation Integrity (CDI) into the clinical environment is challenged by complex physician workflow, perceptions of time, and attitudes towards the electronic medical record (EMR). New innovations such as computer assisted coding and AI-software have shown improved efficiency for CDI specialists and coders. However, more understanding about the impact on documenting clinicians is needed.

Methods

A CDI software with expanded options for query review through EMR, web-based, and mobile application platforms was integrated. Hospital Medicine physicians were surveyed about query platform usage, platform workflow integration, query template clarity, and overall perception of integration changes. CDI query metrics including (1) total query number, (2) response percentage, (3) confirmation percentage, and (4) response time were compared between resident and non-resident groups for 6 months pre- and post-software integration.

Results

Post-intervention surveys were completed by 56 of 116 (48%) resident and 61 of 108 (56%) attending physicians. Mobile application platform use was highest among both resident (86%) and attending (89%) physicians. All platforms were reported as effective in clinical workflow integration. New templates improved ease of locating and understanding the query. Post-intervention, an increase in overall query volume was noted. However, average query response time, completion rates and confirmation rates all improved on both resident and non-resident groups. Overall, the software integration was reported as a positive change.

Conclusions

CDI integration into the unpredictable clinical environment can be successful when innovations promote flexibility for physicians with varied clinical and documentation experience.