Clinical documentation, which includes a record of exams, symptoms, diagnoses, medications, tests, treatments and other elements of a patient’s medical care, plays a vital role in creating a complete picture of an individual’s health and is needed to develop effective care plans. It also ensures that all providers who see the patient have access to a complete, accurate medical record. Incomplete or inaccurate documentation can lead to gaps in care, drug interactions, conflicting care plans, and suboptimal outcomes.
When shared with patients, accurate, high-quality clinical notes help patients better understand their health conditions and can enhance patient satisfaction and support consumer-driven healthcare.
Physicians Practice defines high-quality clinical documentation as clear, precise, consistent, timely and measurable.
Growing documentation challenges
Clinical documentation has become increasingly complex with ever-changing, more stringent payer regulations and compliance requirements. As a process, clinical documentation is highly manual, time-consuming, and prone to error, which only exacerbates the complexity and leads to deteriorating documentation quality. And poor-quality documentation can cause poor-quality coding. Coders rely on accurate, complete documentation to submit clean claims. Thus, poor documentation leads to inaccurate coding, which can cause rejected or denied claims, excessive claim rework, delayed reimbursement, surprise patient bills and write-offs. Increasingly, it may lead to costly payer audits and takebacks.
The best way to avoid these issues is by implementing a clinical document integrity (CDI) program, whereby clinical documentation is regularly reviewed for accuracy and completeness by a CDI specialist, typically someone with documentation and coding experience. According to the AAPC, this person helps bridge the gap between documentation and coding to ensure an effective CDI program.
One of the challenges of implementing a CDI program is the ongoing shortage of medical records specialists. This shortage may grow as the need for these specialists is expected to increase by 8% over the next eight years. Currently, there are around 15,000 openings each year. The shortage can cause increased stress on existing staff and allow limited time to fulfill CDI tasks.
Because of the increased complexity of documentation and coding, bringing on new and inexperienced staff requires extensive ongoing training to ensure providers avoid experiencing a significant increase in errors and revenue interruptions.
A strategic approach to overcoming CDI challenges
Regardless of the many challenges, there are proven steps providers can take to achieve optimal CDI, which include the following:
- Implement a documentation training program for staff, including physicians. Clinicians and others involved in clinical documentation need to understand how their attention to detail can impact patient care as well as revenue. Sloppy handwriting or incomplete notes can lead coders to guess what a physician meant, especially in busy facilities where physicians can be difficult to track down. Everyone involved needs to understand the importance of documentation and working together to improve CDI.
- Develop a robust review and feedback system. Organizations must implement ongoing documentation reviews leveraging the most qualified specialists possible. This might be an experienced coder with a documentation background or a registered nurse dedicated to CDI. The process should include key performance indicators (KPIs), which would be used to compare CDI initiative success with industry benchmarks and competitors.
- Adopt CDI software. Computer-assisted clinical documentation technology can automate workflows and conduct detailed chart analysis to flag errors and missing information. This enables staff to proactively address these issues so as to improve clinical information and documentation quality while protecting patients and the bottom line.
- Create regulatory specialists. Creating a team dedicated to monitoring and implementing regulatory changes and payer requirements can help organizations achieve and maintain compliance. These teams should regularly update documentation guidelines in accordance with the new requirements.
- Optimize the EHR. Investing in EHR optimization opportunities can help streamline and simplify documentation workflows. While there will be an initial learning curve for staff that includes extensive training, it is essential that they understand the ultimate goal of CDI in improving outcomes and revenue.
- Focus on staff development. Although it may be challenging, organizations must create a robust recruitment pipeline for CDI professionals, which may need to include incentives and competitive salaries. If possible, offering work-from-home opportunities may help broaden the candidate pool beyond the local community. Additionally, organizations should refresh their efforts to foster a culture of continuous improvement and professional development so candidates and existing staff understand that their roles are valued and that the organization is willing to invest in their success. This can go a long way in improving recruitment and retention.
Looking to the future: Innovations in CDI
Just as AI and machine learning (ML) have become a valuable asset to clinical processes, these technologies also present the potential for transforming administrative functions such as coding and clinical documentation. Research indicates that these technologies can be powerful tools for supporting healthcare but with a caveat that they should be “a supplement to existing workflows rather than as a replacement for human expertise.”
At this point, it’s the synergy between the technology and the human expertise that creates the most benefit. For example, AI-enabled automated data entry and documentation can reduce errors associated with manual data input. These technologies can extract relevant data from clinical notes, transcribe clinician voice recordings and automatically populate the information into the EHR. Likewise, AI-powered voice recognition can perform hands-free dictation in real-time directly into the EHR during a patient visit. The technology can be trained to understand complex medical terminology and its use in context, allowing it to create precise medical note documentation. In both applications, clinicians apply their expertise while reviewing the notes, making changes, and giving final approval — a much faster, simpler process than manual data entry.
At a time when the average physician spends nearly two hours a workday outside of the office completing documentation, the application of AI and related technologies can help reduce administrative burden and improve work-life balance while also enhancing staff productivity.
Another great benefit of leveraging AI in CDI is its ability to provide detailed analytics to track and measure things like query volumes and physician response rates to help providers identify their CDI program’s impact on reimbursement and outcomes. This information can be used to identify opportunities for continuous improvement activities like CDI training.
Putting it all together
High-quality clinical documentation is critical for quality outcomes, an optimal patient experience, and timely, accurate reimbursement. It is essential that healthcare leaders drive CDI success by investing in the resources and the latest tools and technologies necessary to support CDI initiatives. For many, outsourcing with industry CDI experts can help. The most effective vendors are those with extensive experience in documentation and coding and using the latest AI-related technologies to automate processes, increase productivity and measure impact and ROI.