The healthcare industry is under immense pressure to contain costs and efficiently deliver care across the population. In the times of rising chronic conditions, aging populations, changing technology, and an increasing demand to improve the quality of care call for transforming the way healthcare is documented, obtained, and delivered.

Diagnostic errors are one of the most critical challenges in healthcare today and inflict the most harm. Here are some rather stark statistics detailing documentation errors:

  • Every 1 in 10 diagnoses is incorrect.
  • Preventable medical errors account for the 3rd most common cause of deaths in the U.S.
  • 400,000 people are lost to medical errors every year.

Valid and precise documentation hence has become critical for delivering value-based care, not only because it helps providers validate the care that was provided but also help share vital patient information and optimize claims processing. This leads to the adoption of Clinical Documentation Improvement (CDI) as a necessary step in obtaining complete and accurate patient information.

Why is improving Clinical Documentation important now more than ever before?

Clinical Documentation Improvement is the process of diligently improving clinical records to ensure better health outcomes for patients and obtain improved data quality and accurate reimbursement. Over the years, the need for CDI has emerged in many ways:

  • Countering overpayments and underpayments: Inaccurate coding, however slight can create substantial payment discrepancies for some clinical conditions. The Recovery Audit Program conducted by CMS revealed more than $990 million in overpayments and about $38 million in underpayments returned to providers in a span of three years, disclosing gaping discrepancies. An effective CDI acts like a critical link ensuring timely and accurate reimbursements and avoiding penalties for non-compliance.
  • Improving clinical workflows: Complete clinical documentation enriched with timely and accurate sets of data, tied to providers’ workflows will enable well-planned collaboration in a network and identification of potential risks, and help improve discharge planning and post-episode care.
  • Improve quality measures: The more complex and severe diagnoses are, the more is the number of quality measures and publicly reported data. Accurately documented information is necessary to ensure the quality of services, support care management and taking improvement measures to sustain quality.
  • Ensure compliance: Healthcare compliance are a moving target and to keep up, healthcare organizations need to have specific and precise clinical documentation, lack of which can result in failed audits, huge fines, and fairly significant financial plunge to counter the issues.
  • Drive better health outcomes: Patients are the center of healthcare, and CDI offers complete, end-to-end information needed to continue care. This apart, clinical documentation also helps healthcare organizations bill patients correctly for the services they receive and improve the patient experience of care.

Data-Driven Clinical Documentation

To ensure clinical data is carefully documented and conveys an accurate picture, healthcare organizations often leverage data at hand. Manually performed CDI, while extremely valuable, still has the possibility of human error and more often than not implementing a data-driven approach in tandem can help achieve meaningful results as below:

  • Comprehensively documented data: Health IT today has offered several possibilities; one of the many is incorporation and documentation of patient data from EMRs to wearable health trackers. Physicians and health coaches can document patient information on the fly, and ensure consistent documentation.
  • Thorough analysis: Analytics enable easy and holistic visualization of captured data and learn about specific conditions, potential complications, and address key targets across the patient population. Moreover, advanced analytics can help organizations learn about drops in their revenue and identify the reasons behind them.
  • Segmenting population: Once the documented data is thoroughly analyzed, providers can segment their patients into two broad categories: the ones who have been missed from the documentation, and the ones who have miscoding and errors. This categorization helps providers learn about how clinical documentation can be improved, and how to address documentation gaps.
  • Stratifying and prioritizing patients: Data-driven clinical documentation also helps in obtaining a holistic view of patients and their health that illustrates the underlying risks and potential complications a patient may have. Once equipped with that, providers can stratify populations and deliver urgent care, whenever needed.

The Road Ahead

As the healthcare landscape modifies itself to suit value-based care, clinical documentation improvement has become important, more so than ever. Healthcare organizations are focusing on building and sustaining their success and further leverage data to visualize industry trends. Although revenue considerations are the major driver, CDI is now a fundamental, strategic part of any healthcare organization and their efforts to improve patient outcomes, enhance clinician adoption of advanced clinical documentation frameworks, ensure compliance and upgrade financial performance. Only with the help of precise and accurate clinical data can healthcare organizations take a step towards delivering value-based care.

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Abhinav Shashank is the CEO and co-founder of Innovaccer, a leading San Francisco based healthcare technology company. He built the foundation for Innovaccer’s success as a leader in population health management and machine learning-oriented healthcare solutions recognized by Gartner, KLAS, Forbes, Black Book Market Research, and others. Abhinav’s continued efforts and ambition enabled the company to flourish in health information technology in the U.S. and acquire over 25 healthcare organizations as customers, with more than 25,000 providers using Innovaccer’s solutions daily. His continued work and focused approach have resulted in the latest round of Series C investment led by Dragoneer, Tiger, Steadview Capital and M12, Microsoft’s venture fund. With his vision for seamless care delivery using unified patient records, Abhinav is now leading the team towards $1 billion in savings for U.S. healthcare. Additionally, Abhinav Shashank is an influential thought leader and a renowned author. Abhinav has published over 300 articles for various international media outlets, was bestowed a coveted spot in Forbes “30 Under 30 Asia 2017: Enterprise Tech” and was recognized by Becker's Hospital Review as one of the ‘Top 60 rising leaders in U.S. healthcare under 40’ in 2019.

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