Skip To Sections
Clinical documentation improvement (CDI) aims to represent a patient’s clinical status into coded data. This data is then used for medical research, quality reporting, financial reimbursement, public health data, and disease tracking/trending. By enhancing clinical documentation, medical data collection, reporting, and digital health technology, hospitals will improve their cost efficiency, thus maximizing their revenue and increasing productivity in their organization.
Streamline your clinical documentation, improve accuracy, and unlock the full potential of your healthcare practice.
With the increasing complexity of medicine and healthcare, there is great importance of capturing data accurately for further analysis. Physicians spend about six hours per day performing data entry into patient records, which includes clinical documentation. These administrative tasks detract providers from focusing on patient care, which is what they are trained on. Physician education typically doesn’t include payer rules for clinical documentation, or other factors that influence a hospital’s revenue.
Moreover, physicians typically don’t prioritize improvements in clinical documentation, and consider it to take away time from providing patient care. The implementation of physician advisors, or clinically experienced professionals, can act as a bridge between healthcare providers and other staff to support clinical documentation improvements.
While implementing CDI can improve hospital revenue and efficiency, you should account for potential pitfalls. When creating a CDI program, consider the following:
While you may face these challenges, the overall impact on patient well-being makes CDI necessary for many individual healthcare practices. As employees address the individual challenges, they’ll create a trickle effect that enhances all aspects of the hospital system.
There are several benefits to implementing clinical documentation improvement within your health system. The main advantages of CDI include:
A 2016 Black Book Market Research survey found that nearly 90% of hospitals that implemented CDI earned at least $1.5M more in healthcare revenue and claims reimbursement, showing a clear benefit for hospital revenue.
CDI also advances patient care. When a patient’s record is accurate detailed, healthcare professionals can create more personalized treatment plans. Better documentation not only improves patient care, but also provider performance. The Heritage Valley Health System in Pennsylvania found that better CDI reduced their predicted mortality by 27%, showing clear and tangible benefits. With better clinical documentation, healthcare providers can more easily identify and correct gaps in care. This comprehensive data allows providers to catch a potential complication before it arises, therefore improving patient safety and shortening hospital stays.
Knowing which key healthcare metrics to look for will help you understand how your system works and where to make adjustments. If you want to analyze trends and gaps, Pathstone Partners will assist as you interpret and visualize the data.
The review rate accounts for how many documents the CDI team reviews in a given time. This metric helps administrative staff measure productivity within any organization. You can break this number down by timeframe and assign quantitative goals to each CDI team member.
The query rate is the number of queries per the number of reviews. This number helps leaders notice how their team handles documentation and manages communications.
This rate represents how often staff is responding to queries. You can see which groups are struggling to respond and offer guidance and education to improve this rate.
Your response time is how long it takes physicians to respond to queries once they receive them. You might consider setting a standard response time goal across all teams. Reaching this goal will improve communication and ensure patient needs are met quickly.
The CMI is the average relative weight of all diagnosis-related groups (DRGs) within a hospital. This number determines how sick patients are at any hospital and helps staff calculate payments to meet demand. You should monitor this number monthly and compare it to similar institutions with the same services.
As a leading healthcare management consulting firm, Pathstone Partners can help with CDI in any facility. We work with your team and offer strategies and software that improve performance across the board.
Whether you want to implement a new CDI program or refresh your policies, we can find a custom solution for your facility. Contact us today to learn more about our CDI consulting capabilities!
Find Your SolutionMeet Our Experts
{
“@context”: “https://schema.org”,
“@type”: “FAQPage”,
“mainEntity”: [{
“@type”: “Question”,
“name”: “What Are Clinical Documentation Improvements?”,
“acceptedAnswer”: {
“@type”: “Answer”,
“text”: “With the increasing complexity of medicine and healthcare, there is great importance of capturing data accurately. Clinical documentation improvement (CDI) aims to represent a patient’s clinical status into coded data, which is then used for medical research, quality reporting, financial reimbursement, public health data, and disease tracking/trending. By enhancing medical data collection, reporting, and digital health technology, hospitals will improve their cost efficiency, thus maximizing their revenue and increasing productivity in their organization.”
}
},{
“@type”: “Question”,
“name”: “Why Are Clinical Documentation Improvements Important?”,
“acceptedAnswer”: {
“@type”: “Answer”,
“text”: “Physicians spend about six hours per day performing data entry into patient records, which includes clinical documentation [1]. These administrative tasks detract providers from focusing on patient care, which is what they are trained on. Physician education typically doesn’t include payer rules for clinical documentation, or other factors that influence a hospital’s revenue. Moreover, physicians typically don’t prioritize clinical documentation improvements and consider it to take away time from providing patient care [1]. The implementation of physician advisors, or clinically experienced professionals, can act as a bridge between healthcare providers and other staff to support CDI efforts.”
}
},{
“@type”: “Question”,
“name”: “What Are the Challenges of CDI?”,
“acceptedAnswer”: {
“@type”: “Answer”,
“text”: “While implementing CDI can improve hospital revenue and efficiency, you should account for potential pitfalls. When creating a CDI program, consider the following:
Technology issues: Some outdated technology may make communication and reporting more challenging. While implementing a CDI plan, there may be necessary technology updates as well.
Conflicting information: Some client intake charts may have duplicate or conflicting data with their patient records. CDI can help remove and prevent unnecessary reporting.
Physician engagement: After the CDI system implementation, physicians must comply with new standards and communicate as necessary.
While you may face these challenges, the overall impact on patient well-being makes CDI necessary for many individual healthcare practices. As employees address the individual challenges, they’ll create a trickle effect that enhances all aspects of the hospital system.”
}
}]
}
{
“@context”: “https://schema.org”,
“@type”: “BlogPosting”,
“mainEntityOfPage”: {
“@type”: “WebPage”,
“@id”: “https://www.pathstonepartners.com/blog/improving-clinical-documentation-in-healthcare/”
},
“headline”: “How to Improve Clinical Documentation in Healthcare”,
“description”: “With the increasing complexity of medicine and healthcare, there is great importance of capturing data accurately. Clinical documentation improvement (CDI) aims to represent a patient’s clinical status into coded data, which is then used for medical research, quality reporting, financial reimbursement, public health data, and disease tracking/trending. By enhancing medical data collection, reporting, and digital health technology, hospitals will improve their cost efficiency, thus maximizing their revenue and increasing productivity in their organization.”,
“image”: “https://www.pathstonepartners.com/wp-content/uploads/2021/09/iStock-594058694-150×150.jpg”,
“author”: {
“@type”: “Organization”,
“name”: “Pathstone Partners”,
“url”: “https://www.pathstonepartners.com”
},
“publisher”: {
“@type”: “Organization”,
“name”: “Pathstone Partners”,
“logo”: {
“@type”: “ImageObject”,
“url”: “https://www.pathstonepartners.com/wp-content/uploads/2021/10/pathstone_partners_logo_final_rgb-e1634054351430.png”
}
},
“datePublished”: “2022-05-20”,
“dateModified”: “2022-08-18”
}
This article was authored by Yera Patel. Yera is a senior associate with expertise in performance improvement and non-labor cost reduction engagements at Pathstone Partners.
