Comprehensive clinical documentation can significantly improve the quality and ROI of patient care initiatives. Some of the impact areas include case-mix index (CMI), revenue, physician and hospital admission risk profiling, medical necessity and supply, and recovery audit contractor and compliance.
Regulations like Medicare Access and CHIP Reauthorization Act (MACRA) and Center for Medicare and Medicaid Services (CMS) are impelling the shift from quantity-based to value-based clinical documentation improvement (CDI). As a result, healthcare institutions are increasingly focusing on:
- Hospital-Acquired Conditions (HAC) Reduction
- Hospital Readmissions Reduction
- Patient Safety Indicators (PSI), and
- Hospital Value-Based Purchasing
That being said, despite the intensive focus on CDI, many medical institutions are still largely dependent on manual systems and processes. A 2017 ACDIS CDI Week Surveyrevealed that more than 48% of the respondents do not use computer assisted technologies like computer-assisted coding (CAC) and Natural Learning Processing (NLP).
But implementing computer assisted clinical documentation improvement (CDI) practices does not have to be a difficult task, as long as you follow these five tips.
1. Choose an AI-driven CDI Application
With technological disruptions sweeping across healthcare, AI is being deemed the next big step in the digital evolution of the industry. In fact, 54% healthcare professionals expect widespread adoption of AI within the next five years – clinical practices being the most common application area.
A 2016 study published in Annals of Internal Medicine revealed that about 49% of a physician’s working hours are spent on data entry and only 27% on interacting with patients. This additional workload often spills over after hours. AI-based automation solutions can greatly reduce time spent on clerical work and allow physicians to spend more time on patients.
One of the features of AI-based documentation solutions that health improvement managers (HIMs) could benefit from is NLP. By analyzing the documentation and flagging gaps and ambiguities, NLP ensures high accuracy and specificity in the information being entered into the system. The application checks various components or clinical markers in a patient’s medical documentation. If a marker is found to be missing, it alerts CDI and HIM specialists. For instance, a physician diagnoses a patient for congestive heart failure and makes a relatively generic entry into the system. An AI-based CDI solution will promptly analyze the diagnosis and the medical testing results and subsequently generate an alert to the physician, asking for more specifics about the case.
2. Opt for Cloud-based Solutions over Legacy Software
Cloud technology has been a crucial driver of globalization, by eliminating the constraints of geography and storage capacity in terms of workforce collaboration. A recent study by Persistence Market Research says that the global healthcare cloud computing market is expected to flourish at a compound annual growth rate (CAGR) of 18.9% over the years from 2017 to 2025.
Maintaining health records using legacy software is only a small step up from manual paperwork. It requires ever-expanding storage space and does not enable collaboration across offices. A cloud-based CDI software that meets HIPAA standards, on the other hand, offers off-premise on-demand storage as well as a high degree of privacy. It also facilitates collaborative patient care service, through increased accessibility to available data.
With centralized documentation software, all healthcare professionals who collaborate on one patient’s treatment – doctors, nurses, therapists, and technicians – can remain on the same page throughout the treatment journey. By allowing medical professionals to update information in real time, a cloud-based CDI solution greatly reduces human error and miscommunication. This improves efficiency, eliminates expenditure on redundant CDI efforts, and, most importantly, enhances patient care.
3. Bring Coders, CDI Specialists, and Clinicians Together
Doctors, pathologists, and patient care professionals often resort to non-standard data inputs that may be a result of the lack of internal documentation protocols. But a short sentence or a broad description does not always convey the accurate picture to others involved in the treatment of the patient. In this regard, coders and clinicians need to cooperate and collaborate with CDI specialists to achieve utmost precision in clinical documentation.
A CDI specialist can find redundancies and gaps in the documentation process and recommend ways to improve its consistency, thereby helping the hospital improve quality of care. However, hiring an in-house CDI specialist is not affordable for most hospitals. Advanced and intuitive CDI software enable hospitals to easily implement CDI best practices in the form of automated software upgrades.
4. Focus on Both Financial and Quality Advantages
A managed CDI solution is easy to use and does not require you to invest extensively in Health Improvement Management (HIM) training. AI-driven documentation analysis ensures that only necessary information is captured with a high degree of accuracy in real time. This significantly reduces the number of “discharged not final billed” (DNFB) cases.
As a result, you can enhance quality of care and improve your organization’s reputation. On-cloud or hybrid solutions also contribute to optimization of your annual IT budget. What’s more, a CDI solution that incorporates current regulations and standards ensures that you’re always ready for HIPAA audits.
5. Automate and Centralize CDI Functions
Healthcare institutions continue to rely on legacy documentation methods that create data duplication and information fragmentation. This not only hinders the quality of service but could prove to be a fatal shortcoming in cases of emergency. Every clinical marker and medical record, therefore, needs to be logically indexed and easily searchable. This is where the systematically arranged tools and intuitive data accessibility of a centralized CDI come into play. An easy-to-use dashboard can facilitate smooth and efficient patient care.
The future will see electronic health records (EHR) becoming increasingly available to all stakeholders in the healthcare value chain. Such an ecosystem will spark collaboration not only between healthcare teams within the organization but between the organization and the patients as well. If your patients are empowered with more information about their health, they can take more proactive decisions and work with you to improve their well-being.
To find out more about how AI-based Clinical Documentation Improvement Software can help streamline clinical documentation workflow and improve value-based care reimbursement, request a demo.
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