A recent survey by marketing research firm Black Book, revealed that an impressive 88% of hospitals confirmed quality improvements and increase in case mix index within six months of CDI implementation. Clinical documentation has long been at the heart of any regimen of patient care. The clipboard at the end of beds is long gone. Now replaced by multiplatform access to electronic health records (EHRs), physicians and other care providers have access to immediate and complete patient information.
The Current State of Clinical Documentation
Clinical documentation serves several purposes such as quality reporting, public health data, and disease tracking and trending. But its major focus boils down to effective patient care. The failure to properly document can have severe consequences like:
- Incorrect treatment decisions
- Painful, expensive, and unnecessary diagnostic studies
- A lack of communication between referring physicians and consultants, resulting in a lack of follow-up with evaluation and treatment plans
There’s no single factor that leads to inadequate documentation. Many CDI experts cite the lack of understanding of the specific information that needs to be included. Physicians tend to document a lot of information; however, due to lack of awareness, they don’t use the appropriate words that could provide the highest level of specificity.
Time is another factor that works against providers. The number of patients that a physician or provider is required to examine in a day often leads to a tug of war. For most, the first feeling is their obligation toward the patient, making documentation the secondary priority.
EHRs facilitate better documentation but deliver mixed results at best. The US HITECH Act of 2009 tried enforcing better documentation through a wider adoption of EHRs but making physicians change their process of gathering clinical information is more than just providing an electronic format that could perpetuate unwanted habits.
While EHRs have resolved several legibility concerns and helped improve communication among providers, it has also become the cause of major concerns. Copying and pasting has become so rampant that almost every inpatient record in most hospitals is bloated with the same assessment and plan reiterated across time, impairing original thinking.
The Shift from Volume to Value-based Care
Compliance concerns are always at the forefront of health care organizations’ strategies. Value-based purchasing and other reimbursement issues such as patient safety indicators, audits, and hospital-acquired complications (HAC) are dependent on reliable documentation.
This is why the Centers for Medicare and Medicaid Services (CMS) has implemented ‘pay for performance,’ a value-based approach wherein the quality of care affects reimbursement. ‘Pay for performance’ refers to “an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of healthcare.” That being said, while most CDI experts are aware of ‘pay for performance,’ many are still unaware of how CMS implements it.
The role of CDI in Improving Processes
CDI specialists who use a traditional review process can easily identify HACs as they are limited in number and within the scope of a CDI review (i.e., they’re classified as CCs/MCCs). However, each of the measure types has different inclusion and exclusion criteria, cohorts, and risk adjustment data and methodology.
Clinical documentation in a value-based care requires organizational investment. Incorporating a value-based approach calls for a paradigm shift in CDI approach, including workflow, staffing, and performance metrics. CDI departments need to modify their review processes to consider the impact of risk adjustment or introduce a new review format that solely focuses on the performance of the quality measure.
CDI departments need to operationalize and define clinical quality measures while shifting toward a value-based approach. The work of CDI should not duplicate quality functions or coding; instead, these departments should collaborate to identify gaps in current processes as quality data acquisition moves from abstraction to claims.
For instance, CDI staff can identify those cases that fall within a measure cohort and refer them to the quality department or can refer them to those CDI staff who specialize in value-based reviews.
Making a Difference with ezDI
The growth of the global market for CDI can largely be attributed to its growing solutions segment. Often these solutions implement encoder systems, voice-text-speech recognition, and transcription systems. As a result, CDI solutions accounted for the largest share of the market in 2017.
The options of CDI solutions providers are aplenty. But ezDI stands out as a major performer in the segment. And here’s why.
ezDI transforms clinical data into quality, compliance, and revenue improvement opportunities with ezCDI – its unique cloud- and AI-based clinical documentation improvement software. In contrast to most available CDI software that juxtapose third party modules and patches, ezCDI is organically built and designed from ground up. This makes it unique and offers users with a seamless experience.
The features of our fully integrated, NLP-based, HIPAA-compliant solution include:
Intelligent worklists: Automates time-consuming manual tasks and helps identify the review population, improving CDI coverage. Simultaneously, these also address concepts of revenue cycle management and accurately capture the complexity of the entire patient population and clinical scenario.
Automated query suggestions: Options like “Discuss with Colleague and Electronic Queries” facilitates collaboration with CDI, coding and HIM professionals, physicians, and auditors. On the other hand, this expedites and improves decision-making.
Real-time analytics: ezCDI abstracts clinical data in real time to suggest codes with associated evidence. This helps analyze health records for incomplete, conflicting, complex, or nonspecific provider documentation, streamlining the CDI process.
Unlike traditional software solutions that require users to switch among windows for multiple functions, our solution has all the tools in one place. Each and every element of the platform is intuitive, designed to ensure maximum access to the resources (such as health record, clinical indicators, clinical evidence pertaining to coding, grouping, reimbursement, etc.) through minimal mouse clicks.
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