Standardizing the Metadata of the Clinical Documentation Improvement Content for Future Automation

The lack of standardized metadata in the content authoring tool limited the ability to automatically share, deduplicate, aggregate, and view clinical documentation improvement (CDI) content. Additionally, there has been no way to automate the flow of content from one tool to the next; therefore, moving the CDI content from the authoring tool to the downstream tools has been a manual process. Manual processes can introduce errors at every step and ultimately potentiate misunderstanding and inefficiency, generating more work for all stakeholders. Given the value of standardization and the problems identified with the current tooling used at a health information system company, the goal of the CDI hierarchy standardization project was to design and implement a standard hierarchical metadata structure to organize the CDI rules in the content authoring tool and disseminate it to all downstream tools and applications, which will enable the automation of data flow going forward. To achieve this goal, the following objectives were identified: 1) to define application requirements across the five separate systems currently housing the CDI content, 2) to select an appropriate clinical hierarchy on which to base the standardization in the content authoring tool, and 3) to standardize the metadata in the content authoring tool.