Clinical Documentation Improvement Software - 5 Tools Hospitals Prefer

While clinical documentation is a vital component of healthcare delivery, it can be a significant drain on your time.

If you fail to prioritize it, you risk having incomplete patient records and frequent reimbursement denials. Therefore, to balance the need for complete documentation and administrative efficiency, it is best to use technology to streamline and automate the process.

This post explores the top clinical documentation improvement software you can leverage to achieve this balance.

TL;DR - Best Clinical Documentation Improvement Software

Here’s a quick rundown of the top clinical documentation improvement solutions we’ll cover in this post:

• 360 Encompass

• IodineCDI

• Microsoft CDE One

• Solventum Outpatient CDI

• Epic Systems CDI Module

What is Clinical Documentation Improvement Software?

Clinical Documentation Improvement (CDI) software is a technology solution used to ensure that patients’ clinical records are complete and accurate.

You can use such a solution to:

• Ambiently capture clinical conversations and automatically transform them into structured notes

• Seamlessly support documentation-to-coding workflows

• Flag gaps and inconsistencies in documentation

You can now do the above with minimal manual workflows. With advances in AI, many CDI solutions now utilize Natural Language Processing (NLP) to capture, analyze, and structure documentation in real time.

Why Do Healthcare Organizations Need CDI Software?

CDI software can significantly enhance the administrative efficiency of your healthcare organization.

You will find the documentation solutions valuable for the following key reasons:

• It protects revenue integrity: By streamlining documentation, CDI software helps you avoid under- and over-coding. Every service can be accurately captured with the right CPT and ICD-10 codes.

• It helps reduce physician burnout: CDI software can help you reduce after-hours documentation work by minimizing manual coding and charting. For instance, in a study across 6 healthcare systems that involved 30 days of ambient AI scribe use, burnout prevalence dropped from 51.9% to 38.8%.

• It supports the shift to value-based care: You need robust documentation systems to deliver value-based care, which focuses on quality of care and cost efficiency. Particularly, the solutions can help you align your clinical and financial requirements by streamlining documentation for reimbursements.

Essential Features of Clinical Documentation Improvement Software

While different CDI software vendors prioritize different clinical and operational needs, the best solutions share some common features.

You’ll likely find the following features essential in your specific clinical setting:

• Retrospective chart review to support analysis of existing data to identify care gaps and outcomes without having to collect new data.

• Query workflows to resolve documentation gaps efficiently and compliantly.

• A coding rule engine to align documentation with coding requirements.

• Analytics dashboards to track various measures, including case-mix index, query response rates, and financial impact.

While the above features are valuable for improving clinical documentation workflows, you’ll need additional functionality to ensure broader documentation and revenue integrity.

That’s where DeliverHealth comes in. Our platform sits upstream and downstream of CDI to streamline documentation creation and coding automation.

It impacts CDI outcomes by improving documentation quality, coding accuracy, and revenue integrity.

How DeliverHealth Supports the Full Documentation Lifecycle

DeliverHealth offers AI-powered solutions to streamline documentation end-to-end. It does this with two integrated offerings:

• InstaNote, which is an AI-powered documentation solution that instantly turns your patient conversations into structured clinical notes. It supports both dictation and ambient workflows and includes coding suggestions.

• InstaCode, which is an AI-driven coding solution designed to scale coding capacity and accuracy cost-effectively.

These enterprise-grade documentation solutions combine the following key capabilities to improve clinical and administrative workflows:

• Ambient Clinical Intelligence (ACI) technology to listen to your encounters with patients and draft notes in real-time without “filling in the blanks” with unsaid details.

• Automated note structuring capabilities using your healthcare organization’s preferred templates and formats.

• Autonomous coding leveraging Natural Language Processing (NLP) to read notes and independently assign codes.

• Standardized documentation inputs and customizable validation rules to increase coding productivity without sacrificing accuracy.

Also, our platform seamlessly integrates with popular EHR systems like Epic, Haiku, and Athena. You can deploy either InstaNote or InstaCode as a standalone solution or combine them to unify your documentation and coding workflows.

Ready to see how DeliverHealth supports end-to-end documentation workflows?

Request a demo to reduce documentation burden and optimize revenue.

Top Clinical Documentation Improvement Software Solutions That Work

If you’re specifically looking for core CDI solutions, we’ve analyzed the top ones that providers across the nation are currently using to drive clinical efficiency.

Below are the top 5 reliable solutions proven to work across a variety of healthcare settings:

1. 360 Encompass

Spun off 3M Health Information Systems, Solventum’s 360 Encompass is a computer-assisted physician documentation (CAPD) software you can deploy in your healthcare organization to capture complete and accurate patient data.

The software can help you achieve various documentation and revenue goals by:

• Reducing documentation errors that increase audit risk

• Enhancing team efficiency with ICD-10 by reducing generic unspecified codes

• Improving claims accuracy to improve reimbursement rates

Also, 360 Encompass integrates with popular EHR systems, enabling queries to be delivered within your existing EHR workflows to enhance efficiency.

The platform is limited on the note-taking side. It may not be a good fit if you want a solution that also comprehensively supports point-of-care documentation.

2. IodineCDI

IodineCDI is offered by Iodine Software, which is now part of Waystar. It is designed to help hospitals and large health systems solve mid-revenue cycle pains.

The software runs an AI engine called IodineIQ that blends NLP with Generative AI and Large Language Models (LLMs) to support its clinical judgment features.

You can use IodineCDI for:

• Identifying documentation gaps

• Prioritizing charts that may contain inconsistencies for review

• Supporting post-discharge audits to secure additional revenue and reduce denial rates

The software integrates with popular EHR systems.

The platform may not be a good fit for a small- or medium-sized healthcare organization, as it is primarily designed for large health systems.

3. Microsoft CDE One

Offered as part of Microsoft Cloud for Healthcare, CDE One is a solution designed to help CDI teams improve documentation quality and streamline clinical and coding workflows.

Depending on your needs, you can request Microsoft to tailor CDE One to your specific workflows by adopting only the features you need.

You can use the CDI software to do the following:

• Identifying documentation gaps with prioritized worklists that enable your team to focus on charts with the highest quality or financial impact.

• Quickly surfacing clinical evidence within your own patient record using an AI-powered Clinical Decision Support assistant.

• Streamlining documentation workflows with the help of centralized codebooks and coding clinics.

The enterprise-grade platform integrates with popular EHRs, including Epic and Athena.

It may not be a good fit if you want a solution that supports the full documentation workflow, including point-of-care documentation creation.

4. Solventum Outpatient CDI

While 360 Encompass provides a CDI platform mostly focused on inpatient settings, Solventum Outpatient CDI is helping the company expand into the ambulatory space.

You can use the solution to support the following documentation improvement tasks:

• Surfacing patient risks alongside care optimization opportunities.

• Integrating advanced clinical models to build comprehensive profiles of chronic conditions and performance metrics.

• Streamlining workflows for your staff working on documentation, including risk reviewers and coders.

It may not be a good fit if you want a unified solution for both inpatient and outpatient care.

5. Epic Systems CDI Module

Epic offers embedded CDI capabilities within its EHR. It’s designed to make CDI part of your clinical workflows while using the platform.

You can find the capabilities within the Health Information Management (HIM) system, documentation interfaces, and coding workflows.

The module can help you:

• Look for query opportunities within your clinical documentation.

• Send queries directly through Epic’s messaging system.

• Review documentation in real-time with customizable worklists.

It may not be a good fit if you need a dedicated CDI solution with extensive analytics and reporting features.

Tips to Measure CDI Software Success and ROI

After choosing and implementing your preferred CDI software, the next stage is to evaluate its impact on your healthcare organization.

Here are some tips to measure success and ensure you’re seeing a positive return on your investment:

• Focus on key KPIs: To measure documentation quality, track performance indicators such as query rates (how often your CDI specialists request clarification) and query response rates (how often you actually respond to those requests).

• Track revenue measures: You want to directly track revenue impact by measuring improvements in revenue capture, the number of personnel hours saved per chart, and reductions in denial rates.

• Keep an eye on the Case Mix Index (CMI): CDI software should significantly improve your documentation of the average clinical complexity of your patient population. If it's successful, you should see improvements in your ability to fully capture comorbidities, patient acuity, and other specific diagnoses.

Frequently Asked Questions (FAQs)

Let’s now answer some commonly asked questions about clinical documentation improvement software.

What Role Does Artificial Intelligence Play in CDI Software?

AI is helping streamline charting and coding in clinical documentation improvement software.

Ambient clinical intelligence, acting as a digital scribe, now enables CDI software to record patient-provider conversations in real time. Also, AI analyzes notes and images to suggest the most accurate codes.

How Does CDI Software Support Risk Adjustment And Value-Based Care?

Value-based care models, such as Medicare Advantage, tie reimbursement to your patients’ risk score derived through risk adjustment. CDI software can help you accurately document every chronic condition, enabling proper mapping to Hierarchical Condition Categories (HCC).

Also, because value-based care rewards outcomes (not volume), CDI software helps ensure accurate documentation that you can leverage to support quality and reporting frameworks such as the Healthcare Effectiveness Data and Information Set (HEDIS).

Is Clinical Documentation Improvement Software HIPAA Compliant?

Yes, it’s a baseline requirement. Beyond HIPAA compliance, platforms like DeliverHealth’s eSOne are also HITRUST i1 certified, offering the highest security standard in the healthcare space.

How Long Does It Take to Implement a CDI Software Solution?

Implementation time varies depending on the software vendor and the procuring healthcare organization. Generally, you can expect implementation to take a couple of weeks.

Conclusion

The CDI solutions we’ve discussed above are some of the best in the industry right now.

However, CDI is only one part of ensuring broader documentation and revenue integrity. You must look beyond retrospective review and query workflows and also focus on improving documentation earlier in the process.

At DeliverHealth, we offer a robust clinical documentation solution that aligns with coding from the start. With InstaNote and InstaCode, you can streamline the full documentation lifecycle, improving documentation quality and coding accuracy.

Learn how our AI-powered solutions can help you streamline documentation end-to-end.