As healthcare providers transition to value-based care, it is vital to use data that has been accurately recorded and documented. Clinical documentation improvement (CDI) assists in ensuring that all events in the patient encounter are accurately documented and that the EHR Software displays the services that were provided to the patient. Accurate diagnosis can enhance patient outcomes significantly, and clinical documentation improvement can reduce documentation errors.
The Benefits of Clinical Documentation Improvement in Healthcare
The American Health Information Management Association (AHIMA) explains on its website, that clinical documentation improvement programs can help to support the precise depiction of the patient’s clinical status. This clinical status is the coded data which is later translated into meaningful quality reporting, public health data, and clinician’s report cards. CDI also facilitates that the entire members of the care team get the right information about the patient, this keeps teams well informed about the patient at the point of care.
When a CDI program is implemented claims can be filed on time. This can combat the issue of denied claims. There are financial benefits of clinical documentation improvement. 90% of hospitals with outsourced clinical documentation processes realized gains of $1.5 million in claims revenue and claims reimbursements according to a 2016 report released by the Black Book Market Research fund. There is a boost in practice revenue as errors are reduced and medical coding is accurate.
CDI programs help verify that healthcare providers are in compliance with all regulatory standards. This reduces the likelihood of audits and penalties. In addition, accurate recordkeeping safeguards healthcare institutions from malpractice claims.
CDI programs and Improvement in Patient Care
Medical records can be improved in hospitals through complete and accurate documentation with the help of CDI. Clinical documentation captures complete details of patient care from hospital admission to discharge. This also includes diagnosis and treatment. When this documentation is clear and precise it helps to rule out any confusion and also improves communication between healthcare providers. On the other hand, if this documentation is inaccurate then it could diminish the quality of patient care which can lead to medication errors, longer stays at the hospitals, and higher re-admission rates.
Physicians also have to deal with long hours with Electronic Medical Records (EMR) Software data entry and administrative tasks which cuts down their quality time with the patient. Clunky EHR software designs keep the provider overworked. However, workflow documentation tools such as pre-structured data elements can streamline the documentation process providing an opportunity for the doctor to focus on patient care which is the ultimate goal of healthcare.
Enhancements in Clinical Documentation Improvement
Technology, such as computer-assisted coding (CAC) and natural language processing (NLP) software, has been widely used to improve CDI processes. CAC employs algorithms to aid in the detection of potential coding errors, whereas NLP aids in the extraction of useful information from unstructured clinical data.
To enhance documentation procedures and guarantee proper reimbursement, CDI programs work with other divisions. These include coding, quality improvement, and revenue cycle management.
Moving Ahead
Healthcare organizations will continue to deploy CDI to ensure data quality and reporting to monitor outcomes and make informed care decisions to improve health outcomes.
