Hesitant to invest in clinical documentation improvement (CDI) because you’re worried it’s only a temporary initiative? Discover why CDI is a long-term venture that isn’t going anywhere.
Four reasons why CDI is here to stay
From electronic medical records to telehealth and speech-to-text services, technology in healthcare continues to develop rapidly. It can seem like every human based program will one day be superseded by a computer!
And while some processes and technologies will inevitably become outdated, clinical documentation is one aspect of patient care that isn’t going anywhere – here’s why.
1. Patient care requires clinical documentation
Unfortunately, it’s a fact of life that sickness and injuries occur – there will always be patients who require medical care. And where there’s medical care, there’s a medical record. Imagine trying to assess a patient without any previous notes, imaging, letters, or pathology to refer to! Nigh on impossible!
It may even be that as we move forward, documentation is recognised as being even more essential to communication and patient safety. As we have improved safety and quality in medicine, and come to expect impeccable outcomes for every patient, documentation has had a huge role to play. Think of the revolutionary, universal, and extremely effective WHO Surgical Safety Checklist.
But even aside from the immediate communication between care providers, other uses of the medical record are not going away.
Research
We will always need to do some retrospective research using data from medical records. While Randomised Controlled Trials (RCTs) are the gold standard of research, for practical reasons, this is not always possible. And even in RCTs, medical records are often used to select patients and assess for inclusion and exclusion criteria.
Medicolegal
As a practitioner, the medical record is your safety net. Sometimes, patients can bring medico-legal cases months to years after the event. Clinicians cannot be expected to remember every single patient! The medical record allows you to remember the patient and defend your assessment and plan. It may be the only way that you can prove that you gave certain advice or counselled them on the risks of refusing treatment.
2. We will always need coded data
Florence Nightingale knew this nearly two centuries ago. She said “Improved statistics would tell us more of the relative value of particular operations and modes of treatment… and the truth thus ascertained would enable us to save life and suffering” (Notes on hospitals 1859, revised 1863). We will always require information on the health status of the inpatient population in a format that can be easily manipulated to answer questions and determine resource allocation.
And as the algorithms to do this become more sophisticated, the integrity of data becomes even more important. The result an algorithm gives is only as useful as the data fed into it is accurate.
The data extracted from the documentation through coding requires constant scrutiny to ensure that it’s accurate and relevant. In other words, data quality and integrity are primarily dependent on the precision of the clinical documentation and clinical coding. A CDI program maintains the quality of documentation, therefore maintaining the veracity of data.
3. More and more hospitals are moving to casemix funding
Casemix funding is a method of allocating funds based on hospital activity and on the types and number of patients treated.
In the casemix funding model, hospitals receive funding based on the relative cost of patients treated. Funding also rewards improved performance and efficiency.
This funding is determined mostly by the codes assigned by clinical coders, and the resultant Diagnosis Related Group (DRG). DRGs represent groups of patients with similar conditions who required similar hospital services.
Around the world, hospitals are moving away from block funding to casemix funding or DRG-based funding. In this model, a hospital’s funding is entirely dependent on:
CDI is an ongoing support service that ensures the information in a patient’s record is accurate and that the DRG reflects the clinical truth – so hospital funding is appropriate for the services provided.
4. Hospitals are focusing more on value-based healthcare
There’s an industry-wide push towards value-based healthcare, which is healthcare driven by health outcomes, as opposed to a fee-for-service or a capitated approach.
The value-based healthcare system identifies quality patient outcomes and ensures these are front and centre in all healthcare delivery.
Around Australia, governments are encouraging clinicians and healthcare executives to move resources away from low-value care and invest in high-value models of care.
CDI is an example of value-based healthcare. Improving the quality of clinical documentation improves patient safety through clear and concise communication between clinicians. Furthermore, improving clinical documentation has the potential to reduce the risk of medication errors, hospital acquired complications (HACs) and readmissions, and the frequency of sentinel events.
The final word
CDI programs are rapidly evolving, in Australia and internationally. There is growing industry-wide awareness of CDI’s integral role in hospitals and healthcare systems.
Because it underpins patent care, strengthens hospital sustainability, and enhances data integrity, CDI enables hospitals to achieve their fundamental organisational goals and values.
CDI is a journey, not an event – and it’s here to stay.
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