Canadian hospitals are increasingly measured and compared based on the data submitted to CIHI and provincial ministries. This has led to the prioritization of clinical documentation improvement programs and increasing adoption of concurrent coding.

Clinical documentation is the roadmap of a patient’s journey throughout a health system. It is also increasingly becoming the basis through which many providers are measured and compared. As a result, the accuracy of the documentation is paramount and providers are prioritizing the quality of clinical documentation and the resulting data that is coded and submitted to the Canadian Institute for Health Information (CIHI) and provincial ministries. Most health providers are implementing clinical documentation improvement (CDI) programs that will ensure high-quality documentation is developed to improve patient outcomes and enable better operational planning.

According to the Canadian Health Information Management Association, CDI training and development is fundamental to the future of health providers, as it delivers the following results:

• High-quality clinical documentation that accurately reflects top-quality care delivery
• Improved submission data for CIHI and provincial ministries
• More accuracy in the reporting and analysis of provider data and information
• Greater capacity for accountability and quality surrounding patient outcomes, and ability to achieve accountability agreements, activity-based funding models, and other quality-based initiatives
• Optimized submissions for potential funding and data that reflect costs correctly

Clinical Documentation Improvement Programs Are Inhibited By Current Processes

Today, in general, physicians and other health providers write clinical notes as they provide care to patients or just after a visit. Patient records are later sent to be reviewed and coded, and the resulting data is then used for analysis, reporting, and funding. This process has been in place for decades but it leaves gaps in the system for errors to occur and fails to prioritize real-time improvement. 

The challenge with clinical documentation processes is that notes may contain errors or lack appropriate details to help medical coders accurately assign diagnosis and procedure codes. Such is understandable given that documentation skills are not a part of formal education for healthcare workers. But, with the long backlog of charts coders face, it may take weeks or months to issue a physician query, at which point the information is no longer top of mind for physicians. This exacerbates the problem and emphasizes the onus put on healthcare organizations to implement and prioritize clinical documentation improvement programs. The manual nature of medical coding and auditing also means that CDI teams do not have access to valuable coded data for effective CDI programs until weeks or months after care has been provided and paperwork was initially created.

Improving Clinical Documentation Requires Real Time Data

Clinical documentation improvement is inhibited by limited access to high-quality, accurate, and timely data. By reducing the month-long backlogs, coders can also issue timely physician queries for more information. Given that the care is more top of mind, this opens up the opportunity for more detailed reporting that would otherwise be impossible to create. In addition, when armed with real-time information, CDI teams can monitor metrics compared to long-term goals and create actionable plans to tackle areas of improvement. With this, teams are able to identify timely CDI opportunities that can create impactful changes for health information teams, not months down the road, but quickly. Accessing this information requires new technology that simplifies coders’ and auditors’ workflows and helps teams to minimize manual, repetitive work and prioritize complex clinical cases. 

At Semantic Health, we believe that the way forward is concurrent coding.

Concurrent coding occurs when patient charts are coded while patients are still in the hospital, rather than days, weeks, or even months after discharge. The Semantic Health Information Platform does this by analyzing clinical notes in context as they are created and suggesting the appropriate medical codes throughout the patient admission. By limiting the manual review of charts and using highly sophisticated models trained on real, relevant patient data, this platform increases the efficiency of coding and auditing by more than 50%. It also enables timely physician queries for missing information. More so, it reduces the chart backlog so that the data CDI teams review and utilize is near real-time.

• Read more: What concurrent coding means for your hospital >>

With real time data, CDI programs can better address the shortcomings in current workflows and continuously compare results to long-term goals. This ensures that CDI is improving patient outcomes and enabling better operational planning and that the documentation is reflecting these changes.

Investing in CDI training and development will benefit health providers long-term. If you’re interested in learning more about how concurrent coding can help your CDI programs, please contact contact@semantichealth.ai to learn more.