Clinical documentation is crucial to every step of a patient’s healthcare process. From providing physicians the necessary information to diagnosing a patient for proper treatment, clinical documentation enables healthcare companies to render high-quality services to patients and accurately record the transactions that are due. Clinical documentation improvement is implemented so that these healthcare providers can give physicians the necessary feedback to improve the said documentation.
HIM program coordinator, Denise Van Fleet of Rasmussen College describes CDI as “an enhancement process that focuses on written documentation so that it accurately and completely reflects the clinical care provided to the patient.” CDI programs can “facilitate the accurate representation of a patient’s clinical status” into coded data, as explained in the American Health Information Management (AHMA) site.
Clinical Documentation Improvement (CDI) will make sure that all this accurately coded data will be transmitted to the proper healthcare providing the team. CDI has quantifiable results: after implementing this to their system, the Heritage Valley Health System of Pennsylvania experienced a 27% decrease in the predicted mortality rate.
There are other benefits to CDI in a healthcare company. Read on to find out how else your business can take advantage of this development.
1. Continuous, Uninterrupted Patient Care
Clinical physicians spend more time on electric health record (EHR) documentation than patient interaction.
A 2016 AMA study reports that only 27% of their work time is spent on the patient, while 49% is consumed just for EHR documentation. In addition to more time being spent on records alone, they input an additional average of two hours after their work time for EHR data entry. Doctors spend more time inputting the information rather than observing the proper approach and discussing the treatment with the patients.
Having a proper CDI system enables physicians to do their documentation faster. Features such as pre-structured data elements can improve the documentation so that doctors can focus on the patients more. Phoenix Children’s Hospital used CDI to include 360,000 terms to speed up the record taking or documentation process of physicians. As a result, they were able to finish it in 24 hours, preventing them from bringing their work home.
2. Increased Operational Efficiency
Outsourcing CDI and documentation functions have improved the service quality of many hospitals. Black Book Market Research reported in 2016 that after implementing CDI, hospitals with 150 or more beds had $1.5 million in revenue and claims reimbursement. Documentation alone cannot solve the issues that arise from passing on information from the doctor to the billing department.
CDI is what can improve the operational efficiency of your company. And it does this by directly addressing documentation process flaws that could result in bigger problems such as financial losses, lower-quality patient care, and higher chances of error.
3. Undivided Attention and Improved Specialization Among Medical Staff
A remote team can take care of your CDI workflows. Smaller hospitals or healthcare companies can benefit from the increased efficiency that comes at a lower cost with an outsourced CDI team. An offsite team of CDI nurses delivers that meets and even exceeds expectations at reduced costs compared to larger hospitals that can afford an onsite set of nurses. Instead of face-to-face interaction, an outsourced remote team of CDI nurses uses the EHR system, email, and other online communication tools, removing the need for them to interact with doctors and other staff through personal conversations.
Because a remote CDI team takes care of their documentation needs, both doctors and non-CDI nurses on-site can focus on patient care. Any gaps in the records can be done in their own time and the time spent is reduced because another team takes care of the initial record. Nurses working on CDI can focus on the work, as the busy run of the emergency room or sudden cases in the hospital does not distract them from reviewing medical charts and inputting the correct information. Having the EHR at their disposal lets them talk directly to physicians and refer to any other documentation they have inputted into the system.
According to Black Book Research, 88% of hospitals said that they experienced improvements in documented quality within six months of CDI implementation. Many more hospitals are keeping up with the benefits of CDI in their process and systems: another survey reported that both physician and financial managements view CDI and coding as imperative to their practice.
Want to improve or include a more efficient implementation of your hospital or healthcare business's clinical documentation but don't have the budget or resources? Outsourcing enables you to hire an expert in CDI that can set up a team to do this job for you. Hire an outsourced remote team to ensure patients are diagnosed correctly and your staff can focus on giving quality healthcare.
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