SHM Converge Scientific Abstract ePoster Gallery-The Cdi-Dictionary: Custom Ehr Dictionary to Reduce Clinical Documentation Burden

Pdf Summary

The article describes the creation of a custom Epic spell-check tool, the CDI Dictionary, designed to reduce clinical documentation burden by helping clinicians use terminology that matches CMS and coding standards. Clinical documentation integrity (CDI) specialists often send queries to providers when notes contain incongruent terms, which can increase workload and dissatisfaction. In the six months before the tool’s launch, the Division of Hospital Medicine received nearly 300 CDI queries per month, and a survey found that 40% of hospitalists were dissatisfied with the query process and 55% felt it negatively affected their clinical experience.<br /><br />The CDI Dictionary, launched in November 2022, flags commonly used but noncompliant terms in real time, suggests compliant alternatives, and in some cases autocorrects them. Examples include suggesting “metabolic encephalopathy” instead of “delirium” and converting “urosepsis” to “sepsis secondary to urinary tract infection.”<br /><br />After implementation, CDI queries decreased significantly from 285 to 244 per month over the next six months (p=0.048), a 14% reduction. Among surveyed hospitalists, 59% reported changing their notes based on dictionary recommendations, and 85% of those who commented on usability found it easy to use.<br /><br />The authors conclude that the CDI Dictionary was user-friendly, influenced clinician behavior, and reduced CDI query volume, thereby lowering administrative burden and potential frustration. Because it uses Epic’s native spell-check function, it can be easily shared, updated, and adapted across institutions. The team also notes future applications, including reducing stigmatizing language and improving note readability for patients.

Asset Subtitle

Theodore Peng

Meta Tag

Author List David Sterken, Donna Hays, Sajan Patel, Sandra Oreper, Theodore Peng, Yumiko Abe-Jones

Category Innovations

Concept Clinical Documentation Integrity

Concept CMS Terminology

Concept Coding

Concept Reimbursement

Concept Epic Spell-Check Dictionary

Distinguished Finalist

Presenter Organization University of California San Francisco

Presenting Author Theodore Peng

Track Technology in Hospital Medicine

Keywords

Epic spell-check tool

CDI Dictionary

clinical documentation integrity

CMS coding standards

clinical documentation burden

CDI queries

hospital medicine

compliant terminology

real-time autocorrect

administrative burden

Clinical Documentation Integrity

CMS Terminology

Coding

Reimbursement

Epic Spell-Check Dictionary