Thought leadership
Poor documentation could unravel the healthcare system as we know it
Corti’s CEO, Andreas Cleve, believes our future health systems depend on recording clinical information accurately, today. We sat him down for a chat about his vision for clinical documentation integrity that’s underpinned by AI design.
When you picture the future of healthcare, do you ever think about medical records and documentation?
Corti’s CEO Andreas Cleve certainly does. If you ask him (and we did), good clinical documentation is one of healthcare’s most important tools, ensuring patients get the right treatment, and that providers bill correctly so they can stay afloat and keep providing vital services.
And beyond that, the CEO says that good documentation even has the power to make healthcare more equitable and accelerate diagnostics research, so we can identify diseases faster.
With all that potential, it’s no wonder Andreas is so passionate about clinical documentation integrity (CDI) - the process of ensuring medical records are accurate, complete and reliable.
“If documentation isn’t top-quality, the worst thing that can happen is the patient doesn’t get the treatment they need. It compromises patient safety and puts them at risk.”
Fueled by his personal experiences as a patient and an innovator within healthcare AI, he’s on a mission to help healthcare help more people by improving the way we record clinical data. We sat him down for a chat to explain the concept of CDI, why healthcare can’t afford to ignore it – and just how AI fits into all this.
Poor documentation can affect a lifetime of care
So what does poor quality documentation actually mean? “When CDI is poor quality, it’s missing the five C’s: Clarity, Consistency, Completeness, Context, and Correctness,” says Andreas.
And a major reason healthcare organizations should be on the alert for low-quality documentation is that it can negatively impact a patient’s entire health journey and put their health at risk.
Andreas invites us to zoom out and look at the patient journey over time. Different healthcare teams will come into contact with a patient’s medical record over their lifetime and health journey. If that data is suboptimal to begin with, it will only deteriorate over time as more professionals add input – which ultimately means clinicians don’t have all the information at hand to accurately diagnose and prescribe appropriate treatment.
And this is a challenge that’s hard to fix once an error has been made or information gaps appear.
“As a busy healthcare professional, how do you know if the patient data you’re relying on is based on inaccurate, unclear or otherwise poorly-recorded medical documentation? You need to be able to trust the record you have on hand without looking into it,” says Andreas.
“Keep in mind that we’re also living longer, which means that continuity of care will be even more critical – and that continuity is underpinned by accurate documentation. With aging populations, it’s undeniable that poor quality CDI will not be acceptable in the future.”
A threat to equitable, accessible healthcare
It’s also known that poor documentation is costly – which in turn, could make healthcare even less affordable.
To start, healthcare organizations can’t bill correctly when they have information gaps about services provided – leading to lost revenue or slow payouts that can impact their ability to pay salaries and stay solvent.
Incomplete documentation also risks non-compliance with regulatory standards; which means expensive malpractice cases, financial penalties, and reputational damage to an organization.
And ultimately, it’s patients that pay the price.
“All of these financial risks drive up the cost of healthcare, whether via increased public spending or raising prices for patients. Ultimately, this equates to less time for healthcare professionals to spend time with patients and less money for research to improve treatments and care,” says Andreas.
On the other hand, high-quality documentation would help healthcare systems save money in the long run – and accelerate breakthroughs in diagnostics.
“One way healthcare systems can save money is by speeding up diagnostics – finding the right diagnosis and treatment, sooner. And to improve diagnostics, we need high-quality documentation that meets compliance and data standards and is accessed by the right people to undertake the necessary studies and research. “
“For healthcare to become more equitable, it needs to become more cost-effective – and CDI is key to that.”
Here’s what’s holding providers back from good CDI
So if high-quality documentation is so vital to high-quality healthcare, why isn’t the industry as a whole on top of CDI?
Andreas points to a few systemic factors that undermine sound CDI practices.
For one, clinicians and staff are extremely busy – there’s so little time in healthcare to revisit the chain of documentation and ensure it meets the 5 C’s of CDI (to recap: Clarity, Consistency, Completeness, Context, and Correctness.)
And within this busy industry, clinical documentation is usually only ever revisited once an incident has occurred. He says that poor CDI is also compounded by the fact that second opinions – which could catch gaps in documentation – are also rare in healthcare due to resources and time constraints.
“All healthcare staff are left with, is their blind trust that a document contains all the information they need to support their patient,”
He says that another enemy of CDI is simply that we haven’t historically had the tools to uphold the highest data standards in a systematic way.
“From an outside perspective, it might look like healthcare organizations consider CDI as an afterthought because it is so difficult to do in a data-driven, scalable way – but human clinicians have been doing the best they can with what they have,” Andreas adds.
“What is ultimately needed is a scalable strategy for using exponential technology to do some of the work on autopilot and offer second opinions, making sure nothing is missed.”
Harnessing AI for CDI
A CDI strategy underpinned by AI tools could help tilt the healthcare system towards a more data-driven environment that’s proactive about good documentation instead of reactive when a problem becomes obvious.
Healthcare professionals, like any human, don’t have the time to identify every single pattern or read every new research paper. Exponential technology could be applied to patient encounters to ease that pressure – so clinicians no longer have to catch every potential angle or diagnostic possibility in a consultation, but can instead invest more time listening and making eye contact with patients.
“I often tell people to picture an AI that can draw on the latest research and studies and offer a second opinion or set of eyes in real-time, rather than having a clinician revisiting the documentation when they have more time to fill it out – because usually that extra time isn’t there,” says Andreas.
“Instead, a healthcare professional can be supported by an AI tool that ensures nothing is missed or goes undocumented during the patient consultation.”
How Corti is changing the landscape for CDI
“Corti is building the most trusted AI for healthcare. Any healthcare professional can plug Corti into every workflow and have an AI uniquely trained on healthcare data to ensure the best possible documentation and care.”
Andreas explains how Corti’s approach is twofold:
“First, the technology is built in a way that can take part in conversations at scale – so the technology is more affordable, faster, and more accurate than other healthcare AI technology. It’s highly attuned to the local environment, so healthcare providers get scalable intelligence built on a global brain, which has their local brain.”
“And because it’s affordable and easy to implement, every provider can start using it as part of their every day,”
“Secondly, it’s built to be proactive, rather than reactive. Most AI take notes – or try to. The problem is that straight note-taking will only exacerbate or amplify mistakes. CDI means adding a global and local brain to the room with the clinician, so they can always access a second opinion from a digital system that remembers all the interactions you’ve ever had and can draw on them. And it prompts and nudges to ensure nothing was missed that should be in the documentation.”
So instead of having an AI or digital tool that takes your clinical notes like a scribe, you can have AI that can co-pilot with you as you take those notes – ensuring that what is documented is as accurate and comprehensive as possible.
Andreas mentions that this respect for clinicians and their work is what drives Corti’s vision for AI and CDI.
“In this way, we’re turning healthcare for AI on its head, aiming to create technology that will not replace the human in the room in healthcare, but empower it. Because the value of a hospital is the care they give; it’s not the machines they’ve bought or the house they’ve built”
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For more explainers on CDI and why it matters, check out our previous piece CDI: Why good documentation is healthcare’s secret weapon.