Electronic Health Records

Adoption & Implementation News

Clinical Documentation Improvement Vital for Patient Care

By Vera Gruessner

- Clinical documentation improvement programs lie at the heart of quality patient care and should accurately show a patient’s clinical status as well as inform which services were provided. According to the American Health Information Management Association (AHIMA), clinical documentation improvement programs transfer patient’s medical information into coded data, which is then part of quality reporting, claims reimbursement, public health information, and disease tracking.

Clinical Documentation Improvement Programs

Health information management (HIM) professionals work as both coding experts as well as clinical documentation improvement strategists within their organizations to ensure meaningful information is captured.

In particular, clinical documentation improvement experts remain dedicated to ICD-10 implementation and the adoption of strong EHR systems across the healthcare continuum. HIM professionals work to assist physicians in remaining compliant with all patient documentation requirements.

Some policies that need to be followed when implementing clinical documentation improvement programs are hiring staff with the right education, experience, and credentials as well as ensuring ongoing education and training for such staff, according to AHIMA. The major roles that healthcare providers have in ensuring their clinical documentation is solid are reporting medical decision making, diagnostics, treatment plan, and outcomes of tests, treatments, and other procedures.

One partnership that is targeting clinical documentation improvement is Nuance Communications, Inc. and medical care predictive analytics company Jvion, according to a joint press release. The two companies are looking to better assist healthcare providers in meeting the requirements of a value-based reimbursement model.

Many medical facilities will likely experience various challenges when transitioning from a fee-for-service payment model to value-based care. Advanced Practice CDI from Nuance Communications should assist providers in this transition.

“We want to get paid for the quality of care and services we provide,” says Joann Hatton, director of Utilization Management and Clinical Documentation Management at Heritage Valley Health System, in western Pennsylvania. “It’s not about the money, it’s about improving patient care, but the positive financial impact of Nuance’s CDI program was clearly evident.”

When it comes to implementing clinical documentation improvement strategies and clinical quality metrics, Heritage Valley Health System saw a significant drop in their predicted mortality rate. This particular rate decreased by 27 percent after integrating clinical documentation improvement programs.

“Data drives our practice,” explains Jennifer Woodworth, director of Clinical Documentation Integrity Program at Swedish Health Services. “Physician and hospital compensation is tied to quality metrics, which means to prove that you are providing high quality care you need data. This real-time reporting allows us to drill down to ICD-9 and ICD-10 codes, complications and other specialized details to see how we are doing with the accuracy of physician documentation, and this enables us to create proactive initiatives that maximize our current resources.”

As more health IT tools are developed to assist providers with clinical documentation improvement programs, the healthcare industry will be ready to effectively transition to a value-based care payment model.

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