Clinical Documentation Technology Complements Staff, Fills Gaps Amid Worker Shortages

Clinical documentation integrity (CDI) has a direct effect on patient care, and as documentation requirements become more complex, CDI departments are challenged by workforce shortages that are likely to persist.

HIM Challenges: Mobile Solutions Tackle Query Concerns

From the article in For The Record magazine:

When used together, mobile technology and templates enable physicians to answer queries on their smartphones quickly and compliantly. Furthermore, they increase the productivity of CDI staff by enabling them to spend less time creating and tracking queries and more time reviewing records. Click here to read full article. 

Understanding AI and Its Applications Across Healthcare

Artificial Intelligence (AI) is not a single technology, but rather a field of technology able to perform tasks that normally require human intelligence by using algorithms, heuristics, pattern matching, and other techniques within the realm of computer science. AI has been an area of significant interest for the health care industry for several years, and many health systems, payers, and life science organizations have (or plan to) incorporate AI and automation into their business strategy.

Kona Community Hospital Chooses AHIMA Physician Query Templates to Improve Quality of Health Records

The American Health Information Management Association (AHIMA) announced today that Kona Community Hospital in Kealakekua, Hawai’i, has chosen to use the AHIMA library of physician query templates available in the mobile query platform from Artifact Health, an Iodine solution.

Amid Rampant Provider Burnout, Marketplace Platform Companies Focus On Clinician Experience

During a time of elevated physician burnout, Artifact is helping to ease administrative burden. “Giving providers faster, more convenient mobile solutions will be imperative as we redesign healthcare workflows with post-pandemic learnings.”

Artificial Intelligence Myth Vs Reality: Where Do Healthcare Experts Think We Stand?

Read how healthcare is rich with examples of successful outcomes from AI technology paired with the right clearly defined, narrow problem.

Industry Voices—Not All Automation is Created Equally for Clinical Documentation Improvement

Originally published on Fierce Healthcare

Healthcare system survival pivots on many metrics, but the ability to generate revenue and to evidence high quality of care are two of the most essential.

At the center of both metrics is the clinical documentation process, where an accurate representation of every patient’s clinical experience while in a provider’s care must be recorded.

As simple as it may sound, achieving that accurate reflection of diagnoses, interventions and the clinical picture is anything but simple. Medicine is as much science as it is art, and complex definitions, levels of specificity and complex medical terminology mean that most hospitals struggle to document everything properly, leading to significant lost revenues and under-reporting on quality metrics.

Health systems have answered this challenge by standing up clinical documentation integrity (CDI) programs, staffed with clinicians. As more healthcare revenue is tied to achieving specific quality metrics, the role of CDI has become even more critical.

However, ensuring integrity and completeness of documentation would require health systems to staff CDI teams with an incredible amount of highly trained clinicians to review and correct documentation on every record, every day. The cost and complexity of such an operation is unimaginable, and no healthcare system has the resources to either employ that many people or even find a supply of that many highly specialized staff.

As a result, many health systems are turning to software to support CDI with technology that scales clinical staff abilities and provides intelligent automation. Unfortunately, the challenge that many have run into is how to identify the right technology for their operation.

The promise of automation in CDI

All the work CDI specialists perform requires clinical knowledge—the sort of knowledge that is gained only after decades of academic study and real work experience. Automating that work means that the technology must mirror the same level of clinical thinking that any one of these specialists employs every day.

The challenge is immense. Emulating clinical thinking with software is among the loftiest goals of artificial intelligence in healthcare and requires the most sophisticated, cutting-edge technologies available—not to mention years of training. Even with the most advanced technology, AI has sometimes failed to impress the critics, as we’ve seen multiple reports call out the stumbles of larger ambitioned (but similarly conceptualized) efforts like IBM Watson.

But, while there are still areas for improvement, the truth is that AI still is making a significant impact across the healthcare landscape—and especially within CDI, where success is well documented.

Machine learning is the answer

While CDI is an excellent and proven use case for AI in healthcare, providers should understand that not all AI is the same. In fact, many legacy systems that deploy “the wrong type” of AI to CDI are unable to see all the gains possible with the correct deployment.

The key to leveraging AI in CDI is to utilize technology that can truly emulate the way clinicians think. It must read, digest, understand and make statistical predictions on the entirety of the clinical record similarly to how physicians look at all the evidence to assess and diagnose to appropriately provide patient care.

That’s where machine learning holds the key. Machine-learning is, at its heart, a pattern-recognition engine that can digest a plethora of individual pieces of data, recognize patterns and then use those patterns to make statistical predictions. If properly applied to clinical information, it is a very powerful technology. Fed over time with millions of patient encounters, machine learning begins to emulate the way clinicians think, automating numerous tasks or challenges that otherwise would only be solvable by a human. While it does not replace clinicians, it does reduce clinical staff burden, providing more time to be spent on patient care.

Additionally, by automatically the review of every patient record in real-time every day, cases can be prioritized so a CDI specialist knows what to look at—versus wasting time on those with no documentation irregularities. This type of machine learning interprets the clinical evidence, compares it to the existing documentation and highlights and prioritizes which cases have discrepancies automatically.

Not all AI is the same for CDI

Many legacy applications attempt to use another AI technology, natural language processing (NLP), to automate complex clinical tasks. While NLP has some useful applications for tasks like clinical narration—where the dictionary-like “look up” function of NLP suggests a better or more accurate word—NLP is only a partial solution for CDI.

For example, NLP can translate the narrative documentation from the clinician into text understood by a computer. However, unless it’s paired with a machine learning solution that simultaneously reads and emulates clinical decision-making (thus enabling a comparison between what was written and what the clinical evidence says), it’s an inadequate solution to solving the core challenges in CDI.

Additionally, rules-based technology solutions that utilize “rules” or “markers” to automate clinical tasks fail entirely to emulate the way that clinicians think. As a result, they cannot reflect the many permutations of the way clinical conditions are presented.

Robotic process automation (RPA) is another buzzword in healthcare that has been cited as a tool for handling repeatable basic tasks. However, within the mid-revenue cycle (and thus CDI), nearly all tasks have a clinical element, requiring clinical understanding to complete. That means RPA definitionally is not suited for more complex tasks that require higher-level thinking.

Instead, intelligent process automation (IPA) is the right solution, as IPA applies machine learning to RPA to automate complex tasks that require human judgment (much like the work of CDI). Thus, to apply IPA in the revenue cycle, not only is machine learning critical, it also is the only technology available today that specifically emulates clinical thinking and judgment.

The future impact of AI on CDI

As technology gets better at emulating a clinician’s mind, increasingly powerful AI engines will soon be able to capture documentation and coding instantaneously. By accurately automating clinical condition documentation directly into EMRs and identifying the final code set, the process will become even more efficient and will have fewer translation errors.

Ultimately, that means smaller teams will be able to support the entire documentation process, which reduces costs for providers and stress on clinicians.

There is no doubt that managing a health system has become increasingly complex, and that’s especially true for CDI teams that must capture data accurately and efficiently. However, AI has become a critical tool that is truly making an impact in the mid-revenue cycle, and there is much more innovation to come in the next few years. But, while we wait for that larger revolution, it’s important that health systems implement a stable and efficient CDI program now, powered by the right technology.

ChartWise Wins Fourth “Best In KLAS” CDI Software Award

WAKEFIELD, RI— ChartWise Medical Systems, Inc., leading provider of comprehensive, scalable Clinical Documentation Integrity (CDI) solutions, takes top segment honors today with the release of KLAS Research’s 2021 “Best in KLAS” Software and Services Awards. ChartWise leads the CDI Software segment with a score of 92.3. KLAS Research, known among Healthcare professionals for their impartial research and performance benchmarking, collects client data throughout the year to score Healthcare IT solution providers, culminating in the “Best in KLAS” awards.

According to KLAS Research President Adam Gale, “The Best in KLAS report and the awards it contains set the standard of excellence for software and services firms. Vendors who win the title of “Best in KLAS” should celebrate and remember that providers now accept only the best from their products and services. The Best in KLAS award serves as a signal to provider and payer organizations that they should expect excellence from the winning vendors.”

Having won three previous KLAS awards from the organization, ChartWise CEO Steven Mason works to ensure that KLAS Research scores and direct client feedback fuel continued innovation from ChartWise in both technology and end-user experience, “Our team works every day to support our clients and ensure their satisfaction with the company, products, implementation, training, and ongoing support. This award reflects our ongoing appreciation for our customers and our commitment to provide the very best functionality and services to support their CDI program goals.”

Founded by a physician and with a staff that includes clinical specialists and software engineers, the ChartWise approach to client satisfaction is about anticipating future needs as much as listening to current ones. In fact, much of the team driving ChartWise innovation worked previously in a user or client role. Commenting on the “Best in KLAS” accolade, ChartWise Founder and Chief Innovation Officer Jon Elion, M.D. offered, “To me, this recognition is an acknowledgement of the long-standing culture at ChartWise to listen to our customers and to work hard to meet their needs. This has fueled a continuing surge in industry-leading technology innovations and will be the hallmark of our continued progress and success.”

The KLAS scoring is a composite of six key areas, from comments and ratings provided directly by customers. ChartWise scored an “A” rating or better across all of these, which include Culture (A+), Loyalty (A), Operations (A), Product (A-), Relationship (A+), and Value (A-). In remarks from Gale, he states, ““Each year, thousands of healthcare professionals across the globe take the time to share their voice with KLAS. They know that sharing their perspective helps vendors to improve and helps their peers make better decisions. These conversations are a constant reminder to me of how necessary accurate, honest, and impartial reporting is in the healthcare industry.”

KLAS Research will honor ChartWise and the other segment winners for 2021 in a virtual ceremony to be held February 23rd.

ABOUT CHARTWISE: ChartWise Medical Systems, Inc., based in Wakefield, RI, specializes in cloud-based solutions for Computer-Assisted Clinical Documentation Improvement.  AI-driven, integrated, and comprehensive, ChartWise’s scalable Software as a Service (SaaS) assists physicians and clinical documentation specialists and features prioritization, electronic queries, flexible workflow, robust reporting, and denials prevention. Developed by renowned physician Jon Elion, M.D., ChartWise is the only CDI software designed by CDI customers for CDI customers, offering reduced risk, actionable data, and a proven fast ROI. For more information, visit

ABOUT KLAS RESEARCH: KLAS has been providing accurate, honest, and impartial insights for the healthcare IT (HIT) industry since 1996. The KLAS mission is to improve the world’s healthcare by amplifying the voice of providers and payers. The scope of our research is constantly expanding to best fit market needs as technology becomes increasingly sophisticated. KLAS finds the hard-to-get HIT data by building strong relationships with our payer and provider friends in the industry. Learn more at

CPSI Announces Partnership with ChartWise Medical Systems to Offer Enhanced TruBridge Clinical Documentation Solutions to Improve Reimbursement, Compliance and Quality Scores for Providers

MOBILE, Ala. (September 23, 2020) — CPSI (NASDAQ: CPSI), a healthcare solutions company, and ChartWise Medical Systems Inc. (ChartWise), a three-time best in KLAS award-winning computer-assisted clinical document improvement (CDI) company, today announced a partnership that will help healthcare organizations of all sizes improve clinical documentation accuracy and overall medical reimbursement.

To strategically manage costs, while also requiring improvements in the quality of patient care, payers continue to shift from fee-for-service to fee-for-value reimbursement models. However, providers struggle with incomplete or inaccurate documentation that often results in incorrect billing, reimbursement and quality reporting. By leveraging the ChartWise computer-assisted CDI software, physicians and clinical documentation specialists (CDS) have the tools and guidance necessary to improve documentation quality, resulting in reduced claim denials and more accurate reimbursement.

Dr. Jon Elion, founder of ChartWise, said, “We have spent the last 25 years focusing on technology innovations that help healthcare providers work smarter, not harder. ChartWise enables patient care to be delivered in a more efficient and effective manner, while empowering the clinicians and staff with the tools they need every day.”

“TruBridge provides end-to-end revenue cycle management products and services to healthcare organizations of all sizes,” said Chris Fowler, president of TruBridge. “Through this partnership with ChartWise, we will enhance our existing CDI service with the software and technology that will ultimately improve reimbursement for clients. With this electronic health record (EHR)-agnostic offering, we believe there will be real interest in the added value to the bottom line of many healthcare organizations – especially considering the current financial dynamics being experienced during the COVID-19 pandemic.”

Steven Mason, president and chief executive officer of ChartWise, said, “We are proud and excited to have a mutually beneficial partnership that will improve the value proposition of the TruBridge CDI offering. Our award-winning solution with built-in intelligent expertise guides physicians and CDS toward a complete diagnostic picture, automatically analyzing lab data, medications and procedures to help identify complications and additional diagnoses that have not been specified completely in the notes. The result is improved patient acuity determination, quality scores and revenue capture.”

About CPSI
CPSI is a leading provider of healthcare solutions and services for community hospitals, their clinics and post-acute care facilities. Founded in 1979, CPSI is the parent of four companies – Evident, LLC, American HealthTech, Inc., TruBridge, LLC, and iNetXperts, Corp. d/b/a Get Real Health. Our combined companies are focused on helping improve the health of the communities we serve, connecting communities for a better patient care experience, and improving the financial operations of our clients. Evident provides comprehensive EHR solutions for community hospitals and their affiliated clinics. American HealthTech is one of the nation’s largest providers of EHR solutions and services for post-acute care facilities. TruBridge focuses on providing business, consulting and managed IT services, along with its complete RCM solution, for all care settings. Get Real Health focuses on solutions aimed at improving patient engagement for individuals and healthcare providers. For more information, visit

About TruBridge
TruBridge, a member of the CPSI family of companies, provides business and consulting services, and an end-to-end Revenue Cycle Management (RCM) solution. With our arsenal of RCM offerings that include a HFMA Peer Reviewed® product and an HMFA Peer Reviewed® complete outsourcing service, TruBridge helps hospitals, physician clinics, and skilled nursing organizations of all sizes become more efficient at serving their communities. For further information visit

About ChartWise
ChartWise Medical Systems, Inc., based in Wakefield, RI, is a healthcare software firm and the developer of ChartWise CDI, a web-based solution for Computer-Assisted Clinical Documentation Improvement. ChartWise CDI’s built-in clinical intelligence and efficient workflow assists physicians and clinical documentation specialists with increased completeness and accuracy of documentation, risk-adjustment, reimbursement and quality scores. Developed by renowned physician Jon Elion, M.D., ChartWise CDI is the only clinical documentation software that translates clinical language used by physicians into accurate diagnostic language required for documentation and reimbursement. ChartWise CDI has provided a positive ROI between five (5) to eighteen (18) times the cost of the software for every client who has used ChartWise CDI. ChartWise was recognized in the 2016 and 2017 Inc. 5000 List as one of America’s fastest-growing private companies, placing first among all Rhode Island-based businesses on the list each year. ChartWise has also been a KLAS award winner for the CDI software category for three (3) consecutive years. For more information, visit

Forward-Looking Statements
This press release contains forward-looking statements within the meaning of the “safe harbor” provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements can be identified generally by the use of forward-looking terminology and words such as “expects,” “anticipates,” “estimates,” “believes,” “projects,” “targets,” “predicts,” “intends,” “plans,” “potential,” “may,” “continue,” “should,” “will” and words of comparable meaning. Without limiting the generality of the preceding statement, all statements in this press release relating to the prospects of CPSI’s partnership with ChartWise are forward-looking statements. We caution investors that any such forward-looking statements are only predictions and are not guarantees of future performance. Certain risks, uncertainties and other factors may cause actual results to differ materially from those projected in the forward-looking statements. Such factors may include: risks related to TruBridge’s ability to successfully leverage ChartWise’s computer-assisted CDI software to improve reimbursement for, and add value to, healthcare organizations; the impact of COVID-19 and related economic disruptions which have materially affected the Company’s revenue and could materially affect the Company’s gross margin and income, as well as the Company’s financial position and/or liquidity; actions to be taken by the Company in response to the pandemic; the legal, regulatory and administrative developments that occur at the federal, state and local levels; potential disruptions, breaches, or other incidents affecting the proper operation, availability, or security of the Company’s or its partners’ information systems, including unauthorized access to or theft of patient, business associate, or other sensitive information or inability to provide patient care because of system unavailability; changes in revenues due to declining hospital demand and deteriorating macroeconomic conditions (including increases in uninsured and underinsured patients); potential increased expenses related to labor or other expenditures; and the impact of our substantial indebtedness and the ability to refinance such indebtedness on acceptable terms or at all, as well as risks associated with disruptions in the financial markets and the business of financial institutions as the result of the COVID-19 pandemic which could impact us from a financial perspective. Numerous other risks, uncertainties and other factors may cause actual results to differ materially from those expressed in any forward-looking statements. Such factors include risk factors described from time to time in CPSI’s public releases and reports filed with the Securities and Exchange Commission, including but not limited to, CPSI’s most recent Annual Report on Form 10-K and Quarterly Reports on Form 10 Q. We also caution investors that the forward-looking information described herein represents CPSI’s outlook only as of this date, and CPSI undertakes no obligation to update or revise any forward-looking statements to reflect events or development after the date of this press release.

Artifact Health joins ACDIS Radio to discuss queries and front-line workflow during COVID-19

Marisa MacClary, CEO and Co-founder of Artifact Health joins The ACDIS Podcast: Talking CDI as a special guest along with Jennifer Cavagnac, CCDS, Assistant Director of CDI, and Nageshwar Jonnalagadda, MD, MPH, FACP, FHM, Hospitalist and Physician Advisor, of Baystate Medical Center in Springfield, Massachusetts to discuss the impact of COVID-19 on Baystate’s physician query workflow. Listen to the show here.