Accurate clinical documentation tells the true patient story – and prevents billing gaps and missed revenue. “Clinical Documentation Integrity” (CDI) is the process of ensuring documentation is top-quality – and it’s ripe for digital disruption.
High-quality clinical documentation is the backbone of healthcare.
It might not make for a thrilling TV storyline in a medical drama like ER or Grey’s Anatomy – but
practices like health information management and comprehensive medical reporting have tremendous power to shape patient outcomes for the better and raise healthcare revenue to keep providers in business.
Almost like a secret weapon for healthcare, flying under the radar.
Clinical documentation shapes patient outcomes
Documentation never sounds as exciting as the actual, hands-on work of treating a patient and helping them heal. But clinical documentation is one of the linchpins of the treatment process - serving as the ultimate source of truth.
That’s because quality documentation – and the corresponding coding derived from it – tell the full patient story, accurately reflecting a patient’s medical status and care history. Clinicians and carers across a patient’s lifetime will depend on that information to mitigate risks and provide the best possible care to a patient.
…and it keeps healthcare providers financially stable
Clinical documentation is also vital for the healthcare bottom line and keeping providers running. Accurate medical records and subsequent coding specify the exact scope of all services delivered to a patient, so healthcare organizations can bill correctly, collect revenue and balance budgets.
…and it helps providers make better decisions all-around
Zooming out, the benefits of quality clinical documentation have the power to transform entire organizational cultures – as one Australian study put it: “when clinical documentation integrity (CDI) is poor, decisions based on these data will be correspondingly poor. When CDI is good, the corresponding data support good decision-making and policy development.”
But the documentation needs to be of the highest quality
Clinical documentation is certainly at the heart of every patient encounter, but in order to be meaningful, the documentation must be of the highest caliber. That means clear, consistent, complete, precise, reliable, on-time, and easy-to-read. The World Health Organization’s definition of data integrity is helpful here, too.
Poor documentation hurts patients and revenue
On the flipside, the cost of poor documentation processes is high. Gaps in documentation and the subsequently coded data can negatively impact health outcomes like a patient’s length of hospitalization, mortality rates, and many other health indicators.
And then there’s the financial hits. Missing or incomplete documentation of diagnosis or treatments can result in payers denying or delaying full payment – which in turn, drains healthcare providers of the revenue they need to maintain their vital medical services.
In fact, one recent study found that rising inpatient claim denials cost hospitals $1.2 billion in revenue.
Is it time to build a document-centric strategy?
That’s why the most forward-thinking healthcare organizations are fostering a documentation-centric culture, using specialists and technological innovation (more on that later) to help with the transition.
That’s where the concept of clinical documentation integrity (CDI) also comes in.
What is clinical documentation integrity?
Now that we’ve established that top-quality clinical documentation is the linchpin of patient treatment – CDI is the process of ensuring those medical records are complete and accurate.
As an emerging concept in the industry – or one that’s flown under the radar for a long time – you might also hear it referred to as “clinical documentation improvement.”
CDI involves rigorously reviewing and updating healthcare records to ensure the highest data quality, recognizing the importance of clinical documentation as a primary health data source with a huge impact on patient outcomes.
A robust CDI program or strategy includes elements like a dedicated CDI team, regular audits, ongoing healthcare staff training in documentation best practices, and leveraging technology to improve documentation.
Significantly, CDI marks a shift away from the idea that clinical documentation is the sole domain of healthcare professionals and towards documentation as a collaborative process between physicians, nurses, coding specialists – and technology innovators too (more on this in a couple paragraphs!).
But CDI is still unchartered territory – and laborious
While the benefits of a strong CDI strategy are clear, it’s still a relative unknown in the larger healthcare ecosystem.
Sound documentation practices also aren’t easy to build, and CDI has historically been manual, time-consuming and vulnerable to human error. Plus, as organizations shift from paper-based documentation to electronic recording, sometimes across multiple systems, it becomes challenging to address legacy CDI.
Some organizations are beginning to introduce CDI programs and deploy CDI specialists to painstakingly scour the medical record and identify missing data or billing gaps, but it’s still very much an emerging role in the industry. And it’s not always sustainable, nor realistic, to have enough CDI specialists to review every patient record, every time.
The result is that many healthcare organizations still find themselves struggling with the challenges of low-quality or unspecific clinical documentation, not to mention finding time for these laborious documentation practices when there’s patient consultations and treatments to attend to.
AI’s huge potential for CDI
In the current healthcare documentation landscape, it’s clear that CDI is an area that’s ripe for digital disruption. And AI innovation is already making an impact – with huge potential for more.
By integrating certain technologies into CDI programs, digital tools can help organizations mitigate the risk of human error in documentation, enhance accuracy, and automate aspects of the process to reduce the administrative burden on physicians.
And it goes far beyond dictation and scribing to help clinicians take notes faster.
Are ambient scribes enough?
When picturing AI for clinical documentation, most people think of ambient scribes. Using a microphone, ambient scribes transcribe a consultation and use machine learning to turn it into a nicely-summarized clinical note.
But while they may help reduce the manual work of note-taking (and allow clinicians to focus on the patient encounter at hand) - ambient scribes have their limitations as a stand-alone tool for documentation integrity.
These tools can lag, exacerbate bias and mistakes, and even “hallucinate” facts that weren’t in the conversation - undermining documentation integrity, rather than aiding it.
Ambient scribes, made more powerful
However, when scribes are combined with other innovative functionalities, they can serve as powerful AI CDI assistants that raise the standard of documentation.
One of the most exciting innovations for CDI is AI with real-time capabilities or “co-pilot” features. This means tools that can provide instant feedback during a consultation, enhancing the quality of clinical notes at the point of care before the information travels downstream.
One example of this is AI that offers real-time nudging during a consultation, reminding users to keep entries in line with CDI standards. Or an “AI co-pilot” that offers diagnosis suggestions to physicians as they document patient encounters, auto-generating relevant documentation and leaving an easily-traceable digital trail for diagnostics. All of this helps a patient’s current care team – and any teams they encounter in the future.
It’s also become possible to use AI to automate medical coding according to the latest coding standards and guidelines, and even learn alternative coding approaches. The best automated tools operate in collaboration with physicians, so ideally the user also can review notes and confirm the diagnosis and procedure codes before submitting, safeguarding the coding process from error.
Conclusion
Research shows that the administrative burden of clinical documentation is a large factor in physician burnout. But we also know that thorough and accurate clinical documentation is vital to the quality of care and financial health of a healthcare organization.
By investing in strong clinical documentation standards and practices, and leveraging AI to elevate the quality of documentation while reducing the administrative burden, organizations can better support clinicians in their work.
Looking ahead to the future, it’s clear that a strong CDI strategy supported by technology will play a key role in enhancing patient care and protecting the financial health of organizations.
Embracing a document-centric culture could be the deciding factor that sets healthcare providers apart.