Clinical documentation is far from an add-on or afterthought. Without it, ICD-10 implementation will fail to achieve its full potential. Instead of taking clinical documentation for granted or moving it down the executive to-do list, healthcare organizations (HCOs)hospitals, health systems, physician practices and medical groupsmust address clinical documentation fully and in parallel to the implementation and optimization of electronic medical record (EMR) systems’ fulfillment of meaningful use (MU) requirements and the transition to ICD-10.
Clinical documentation is in a state of crisis. HCOs continue to copy and paste or pull forward irrelevant and incomplete patient information. By failing to accurately record a diagnosis's specific severity, HCOs can alter decisions over medical necessity, quality and mortality risk. By neglecting to precisely document each diagnosed condition or treatment, HCOs may see inaccurate patient outcome comparisons and may also face losses in revenue. They’re far less able, for example, to minimize denials and suspended claims because payers may question whether services are medically necessary and request additional information.
The challenge of clinical documentation demands that clinicians and healthcare leaders launch initiatives focused on clinical documentation improvement (CDI). Only with CDI can HCOs enhance communication and care decision-making, improve quality reporting and minimize financial risk.
CDI enhances an HCO’s operational efficiency, and minimizes clinicians’ frustration over having to sacrifice time usually spent with patients to address queries. Industry-wide trends toward team-based coordination and collaboration in the interests of value-based care and population health management also call for CDI to enhance patient evaluation, diagnosis and treatment.
Fortunately, CDI is already at the core of many HCOs’ efforts to enhance outcomes, streamline workflows, boost financial performance and achieve full compliance. In doing so, these HCOs have the chance to document the status of populations, integrate quality and outcomes measures and minimize gaps in documentation as part of the transition to ICD-10.
CDI Aids ICD-10 Implementation
Following are several suggestions for how HCOs can use CDI as a platform to aid in ICD-10 implementation:
- Engage clinicians in CDI. By engaging cliniciansphysicians, nurses and allied healthcare professionalsin CDI, HCOs can minimize long-term effects of poor documentation that leads to poor data. CDI initiatives provide a template and launch pad for information sharing, reporting, partnership and collaboration among individual healthcare professionals and care teams. As clinicians discover, discuss and analyze available patient data, they’ll be better able to provide complete, timely, evidence-based clinical care. To that end, HCOs should offer clinicians opportunitiesboth online and face-to-faceto dialogue over possible improvements.
- Zero in on workflow. Offer clinicians the opportunity to document, analyze, evaluate and re-engineer clinical workflowperhaps in partnership with a CDI specialist. By reviewing the thought processes that underlie clinical workflows, clinicians can more easily integrate technologies like mobile devices, speech recognition or natural language processing to enhance patient care.
- Focus on enhanced outcomes. Help clinicians understand how and why more detailed, timely patient data enhances accuracy and promotes consistent communication, resulting in improved outcomes. By linking documentation to clinical workflows, HCOs can help clinicians discover how to collaborate as they zero in on patients with possible complications, initiate early interventions, facilitate discharge planning and control readmissions.
- Show them the money. Remind clinicians how CDI will improve revenues. Through CDI, HCOs can secure more appropriate, timely reimbursement from payors, make the best use of specialists and develop risk-adjusted outcome profiles that ensure accurate payment. Equally important is that they can avoid the audits, penalties and fines that sometimes accompany lackluster compliance.
- Go for the long haul. Remind clinicians that while they may still care for individual patients, they must also care for populations and communities. Focus on how CDI benefits overall patient care across lifestyles and lifecycles and why clinicians need documentation of previous diagnoses and treatments to properly care for consumers and patients over time.
CDI creates a solid foundation for any regulatory change that might emerge in the years ahead. In the short-term, CDI will help HCOs ease the transition to ICD-10 and enhance clinicians’ engagement in patient care improvement, revenue generation, error reduction and operational efficiency.
About the Author: Deborah Neville manages Elsevier's development of an integrated system of on-line curricula and tools spanning clinical documentation, compliance, coding, finance and CDI. She has BS degrees in management/human resources and social psychology. She is a registered health information management administrator and holds a certified coding specialist: physician-based credential. Prior to joining Elsevier, Deborah held positions such as revenue cycle analyst for Mayo Clinic; corporate compliance officer; educator; coding manager; and senior consultant.
As an active member of AHIMA, she has participated in the Quality Initiatives & Secondary Data Practice Council, chaired the Coding Policy and Strategy Committee and Board member for the Society of Clinical Coding. She has authored journal articles, been a presenter of audio conferences and often speaks at national and state conventions.
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