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Clinical documentation improvement (CDI), a vital mechanism in documenting care in the healthcare space, is a strategic necessity that goes beyond a component in the broader revenue cycle management (RCM) of claims processing. It focuses on improved patient outcomes, supports data quality that tells an accurate story of the patient’s care, facilitates accurate reimbursement, and ensures compliance risk management and revenue integrity. With growing automation and digitalization in the healthcare space, legacy CDI solution providers are not able to evolve with payers’ ever-changing regulatory requirements for clinical documentation and coding.

Solution providers are reimagining tools that pave the way for next-generation clinical documentation across the healthcare continuum. The emphasis on detailed clinical documentation and coding will be paramount to personalized treatments, preventing adverse effects (medical reconciliation, hospital-acquired infections, clinical trial mismatches) and optimizing the clean claims rate. As a result, the contribution of various CDI solutions to the overarching RCM portfolio is forecast to increase from 20% in 2020 to 33% in 2024. Regulators prioritize digitally-enabled clinical documentation as they move away from legacy approaches of assessing gaps in payment cycles (clinical documentation after treatment) and aim for transparency, accuracy, and specificity of fund utilization in annual budgets and push for more proactive population health management and prioritized disease-specific CDI. There is a clear need for automation and analytics-based CDI management solutions that leverage the power of machine learning (ML) and artificial intelligence (AI) to achieve regulatory compliance, virtual assistant technology, natural language processing, clinical decision support, and assist with timely decision-making for proper reimbursement and reduce physician burnout.