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It is not unusual for patients to find that their medical history is either missing or incomplete when they visit a doctor. Many physicians voice similar complaints when they try to make a diagnosis, review procedures that the patient has undergone or prescribe proper medications.
Such lapses can directly affect the quality of care that a patient receives, or how the healthcare organization is reimbursed for the services it delivers.
Both scenarios highlight the importance of clinical documentation improvement, and why physicians and coders need to embrace best practices around it. The recently implemented ICD-10 codes certainly add to the challenge, but the overall goals of increasing quality of care while reducing cost of delivery are driving new interest in the topic of clinical documentation.
Clinical documentation improvement (CDI) "is pretty hot right now," said Melanie Endicott, senior director in the health information management practice excellence for the American Health Information Management Association. "It's been around for quite some time, but it is really gaining traction with ICD-10 and the need for more specific documentation."
The stakes are high. Clinical documentation is the critical piece behind health data informatics, or the use of clinical data to make decisions on individual patient care and population health management.
The tangled web of the EHR
Interestingly, it is not the greater health data coding demands of ICD-10 causing the greatest pain around clinical documentation improvement, Endicott said. Just the very move to the electronic healthcare record (EHR) has made the entire process a burden. Coders and developers can -- and should -- go a long way toward simplifying the process.
"I think the EHR has just become so complex," Endicott said. "For a physician to navigate through the EHR, there are many different screens that they have to go through. A lot of times, information is copied and pasted in different sections, so you're seeing a repeat of everything in multiple locations, and you're not sure what is new or if it was from a previous visit. It's really difficult to tell versus the paper world, where it was easy to know what was current on each visit."
Some of the greatest challenges with effective clinical documentation have to do with how many individuals may contribute to a single patient's record, how up-to-date patient information is and how easy it is to distinguish new from historical data, how to ensure data quality and how to protect security and privacy.
What coding and technology steps would help? The following general industry practices are a large part of the journey to success:
- Make sure CDI programs meet compliance regulations.
- Build adequate time into a physician's routine to properly document patient care.
- Educate all record handlers on proper procedures and expectations with record keeping.
- Have data security be a part of the overall process and a goal.
- Ensure that CDI professionals understand clinical terminology.
- Train CDI professionals to ask the right questions but avoid prompting actual diagnosis.
- Consider a clinical "editorial" process in which clinical records are confidentially reviewed for thoroughness.
Better results start with better input
Physicians and nurses must take greater care with inputting clinical data in the first place, said Robert Rowley, M.D., who owns a family group practice in Hayward, Calif., and is co-founder and chief medical officer at Flow Health, a San Francisco company that develops medical data platforms.
That method of thinking can run contrary to the culture at many organizations and with many physicians who are used to making decisions on the fly -- and spending as little time as necessary on recording the experience.
"You've got to document what you can," Rowley said, and sometimes that means "you document what you can to get paid for your work and then move on to the next patient."
The flip side of that notion is an overreliance on physicians and nurses to document properly, and ''then you're going to have as-good-as-time-allows-type of data," Rowley said. "If you don't have other sources of data to supplement what they put in, you will have a pretty incomplete picture."
Data professionals will have little luck at improving their analysis of patient and health data if they are starting with an incomplete data set.
The need for the data clinician
The remedy for many healthcare organizations comes in the form of a new hire: a data professional who can triage clinical data as it enters the pipeline. The job description requires an individual who works hand in hand with physicians to:
- Document a patient's total hospital experience;
- Ensure that all facets of care are captured; and
- Get all of that information into the right digital format, stored in the right places and accessible to the right people.
But just who the right individual is for this role depends on the organization's goals. For example, increasing the quality of care might create subtle documentation differences from trying to increase reimbursement.
"From there you can determine what type of people you want to hire," Endicott said. "That will determine if you should look for coding professionals that know the coding guidelines inside and out, or if you should be looking for clinical professionals that can understand the clinical language that the physician is speaking and be able to help interpret that."
About the author:
David Weldon is a Boston-based writer and editor who focuses on technology, business, education, retirement planning, healthcare and careers.
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