Optimizing Clinical Documentation
Now Is the Time to Get Started
Many healthcare organizations capture clinical documentation via electronic health records (EHRs) and other technology-enabled channels. The ability to fully leverage clinical documentation to improve care, compliance and reimbursement depends on its quality. In my experience, engaging in clinical documentation optimization is a valuable exercise that can yield tangible benefits.
The October 1, 2014 ICD-10 deadline is probably the most compelling reason to focus on optimizing documentation right now. ICD-10 requires a high degree of specificity, and if your documentation doesn’t have it, you could see a drop in reimbursement and/or an increase in claims denials. On the other hand, if your documentation is detailed and reflects a true picture of the patient experience, coders can more accurately code claims, ensuring you receive full reimbursement for services rendered.
While a significant impetus for improvement, ICD-10 compliance isn’t the only driver for optimization. By striving for more detail and accuracy in clinical documentation, your organization can elevate care quality through better communication among providers. Strong documentation ensures everyone who interacts with the patient is on the same page about diagnosis, treatment and patient response. Embedding care alerts and reminders for patients in documentation can further enhance quality.
Comprehensive documentation also ensures you use technology—electronic health records, for example—to its full potential, which can drive physician productivity as well as adoption.
Thorough documentation can also enhance reporting, which in turn, supports better care delivery. Discreet levels of data are necessary to generate accurate quality reports.
Finally, better documentation fosters more timely claims submission, which results in improved cash flow and reimbursement and leads to fewer denials, ultimately preserving your revenue cycle integrity.
Acknowledging the importance of enriching clinical documentation is the first step toward optimization. To make meaningful progress, I suggest organizations consider and customize the following high-level next steps:
1. Establish goals. Be specific about objectives, timelines, training and who will do the work to drive and manage the improvement process and subsequent changes.
2. Determine early focus. High-volume, high-reimbursement clinical areas and processes make a logical place to start work. In my experience, strengthening documentation in these areas can prevent substantial hits to cash flow and revenue.
3. Examine specialties. Concentrate on those areas that have the most significant changes in documentation requirements, such as cardiology and orthopedics. The physicians in these areas will need to significantly “up their game” when it comes to documentation and can provide valuable input for system workflow retooling.
4. Identify areas of “quick wins.” Give special attention to areas of strong physician support because physician champions can serve as positive role models for adoption in other areas. Identify key players within specialties and promote their demonstrated success to break down change management challenges in other areas.
While ICD-10 makes optimizing clinical documentation a top priority now, improvement work in this area should be an ongoing process with the ultimate goal of elevating clinical care. Organizations that commit to a continuous effort to enhance detail, accuracy and consistency, can see real benefits in terms of both revenue and patient care. Although the idea of revamping clinical documentation may seem daunting, organizations can see big improvements with small changes. The key is acknowledging the importance of the work and getting started on the journey; in my mind, there is no time like the present.