How to improve quality of care and revenue cycle integrity through clinical documentation

Improving the documentation of medical treatment in electronic health records improves the quality of care patients receive and has a positive downstream effect on hospitals' revenue.

Traditional clinical documentation improvement, or CDI, processes involve sending retrospective queries for physicians, which creates additional and interruptive work for them. But by changing this paradigm so that clinicians can address gaps in documentation when they are creating the note, healthcare organizations can reduce the amount of retrospective queries sent to physicians. This lessens rework for physicians and, in turn, has a positive effect in reducing clinician burnout, allowing physicians to place a greater emphasis on patient care. High-quality documentation also ensures that hospitals are being properly reimbursed for the care they provide, therefore improving revenue cycle integrity. 

With the COVID-19 pandemic further stressing hospitals' already limited resources, it's critical for healthcare providers to emphasize clinician engagement and efficiency. David Bowers, product manager, and Kathy Harkness, a client engagement executive at 3M Health Information Systems (3M HIS), discussed how to leverage technology to improve clinical documentation and close the loop between clinical care and revenue integrity during an Aug. 25 webinar sponsored by 3M HIS and hosted by Becker's Hospital Review.

Five key takeaways from their discussion:

  1. Focus on quality and accurate revenue becomes a by-product. This is 3M HIS' philosophy to CDI. By focusing on the quality of clinical documentation, healthcare organizations are able to provide higher quality of care to patients. Higher-quality documentation and care then lead to increased revenue integrity and helps providers know that they are being appropriately reimbursed for the care they are giving.

    "When we do the right thing, the right thing happens," Ms. Harkness said.

  2. Leverage technology to improve clinical documentation. Artificial intelligence and other technologies shouldn't get in the way of the patient-physician relationship but should work unobtrusively in the background to make workflow smarter and unified. The 3M HIS closed-loop system uses natural language understanding, a combination of artificial intelligence, machine learning and sophisticated information models using clinical reasoning. It relies on standard ontologies, such as SNOMED, to establish relationships between medical terms and related treatment, findings, procedures, certainty and much more. Leveraging technology makes it possible to proactively reduce care gaps in the CDI process.

  3. Use real-time clinical intelligence to close the loop between clinical care and revenue integrity. Real-time clinical intelligence accelerates the capture of information and provides actionable insights at the same time. The three key elements of closing the loop are capturing clinical documentation, creating insight and driving proactive action. Using a closed-loop workflow improves outcomes across stakeholders.

    "By using a closed-loop workflow, we can drive adoption of technology by lowering the bar for the integration of that technology to improve the user experience and outcomes," Mr. Bowers said.

  4. Improving documentation at the get-go reduces retrospective queries, meaning physicians can spend less time having to go back and complete medical records, in turn helping to reduce clinician burnout. To do that, it's critical to bring CDI education out of the classroom and into the physician's documentation workflow. This helps to improve the quality of documentation at the time of note creation. It's critical to promote an information-driven, consistent and reliable approach to physician documentation as well as to facilitate CDI review of more complex cases with advanced prioritization.

  5. Physician engagement is a top challenge to improving clinical documentation, but it is the key to CDI success. It's critical to engage physicians at the "golden moment," meaning engaging them and educating them within their documentation workflow to avoid needing to bother them later. A survey conducted by the American Hospital Association found that 98.5 percent of CDI programs believe their physicians could improve documentation practices, but 66.5 percent of providers report a lack of understanding of the importance of documentation. To improve physician engagement, the 3M HIS system delivers proactive, real-time, in-workflow nudges. These in-workflow nudges, within the context of the patient, help to improve specificity and results in more accurate documentation, higher-quality patient care and a positive downstream financial impact.

To view the full webinar, click here.

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