Clinical Documentation Improvement: It improves workflow enormously
Recently, we discussed how implementing a Clinical Documentation Improvement (CDI) program that’s overseen by a Clinical Documentation Specialist (CDS) can have a wide range of tangible benefits for hospitals of all sizes.

For that matter, there’s little doubt that it can improve outcomes in all areas of the hospital operations – from the administrative and financial departments, to clinical care and case management.

In case you’re yet to read the article, Is implementing a CDS program and hiring a CDS really worth it?, here’s a quick overview of the key CDI benefits discussed:

  • More accurate and complete documentation – leading to improved analysis and reimbursement
  • Deeper awareness of patient history and casemix complexity – enabling better ongoing care
  • Improved communication between hospital clinical departments, administration staff, allied health professionals and coders
  • Educational benefits – including a better awareness of Diagnostic Related Groups (DRGs) and coding for them
  • More accurate data collection on communicable diseases and health disorders – influencing protocol and policies
  • Historic case substantiation for easier reporting and reviews
  • Greater administration efficiencies
Clinical document specialist talking to a clinical coder
As you’d expect, a CDI program also expedites the coding and auditing process. And does so enormously.

In this article, we look more closely at how implementing a CDI program overseen by a CDS can save HIS departments a considerable amount of time by operating on a ‘first time right’ basis.

Health Information Manager analysing data from different computer monitors

Making workflow

Effectively, a CDI program helps to reduce the time it takes for coders to get clarification on deficiencies in reports. It also delivers more accurate coding first time round. How?

The CDI follows the same logical workflow process that clinical coders take. It also helps clinicians to improve their documentation and meet the Australian Coding Standards.

When a patient record is sent to a coder, the CDI would have highlighted any gaps or anomalies – alerting the coder of any deficiencies that may require substantiation, which the coder can clarify with the CDS if need be.

Since most CDS’ can understand coding themselves or have a high level of medical knowledge, they can often resolve the query themselves. If not, they are on the same floor and within arm’s length of the treating clinicians to gain clarification. This process saves both the coder and medical professionals a substantial amount of time.

The result is more accurate DRGs that truly reflect patient conditions and treatments, along with a far more expedient way of resolving deficiencies in reports. This also means less backlog of episodes for coders, easier reporting for the Hospital Information System (HIS) and more accurate records that lead to better informed ongoing patient care.

Dealing with disparities across departments

In our recent industry report: The growing significance of the HIM and their impact on improving coding quality and data quality, a number of issues facing coders and Hospital Information Managers (HIMs) were highlighted.

The report itself offers many interesting insights regarding challenges HIS departments face – but for the purpose of this article, we’ve highlighted the key finding below:

There are three major factors affecting the quality of coding, and therefore hospital data quality:

  • The need for continuing education and training programs for HIMs
  • Investing in Health Information Technology (HIT)
  • Clear communication to HIS staff from leadership

Clinical coders talking with a Clinical document specialist
The report also uncovered a disconnect between directors and HIS department managers on how much work goes into high quality coding.

Medical records have evolved, and so too has the role of the HIM. HIMs are no longer clerical support to hospitals, instead they work with software, policies, and processes to ensure high quality coding which leads to better business outcomes:

  • Education and training of HIMs affects coding quality
  • Coding quality affects Activity Based Funding (ABF)
  • ABF affects business outcomes

A CDI program supported by a CDS can help bridge the gap in each of these areas. It can also address time pressures of meeting coding quotas – particularly when underpinned by analytics and reporting software.

Clinical document specialist workspace with data sheet and computer

How software can amplify the benefits of CDI

Instead of relying on Excel spreadsheets, analytics and reporting software offers an integrated system with real-time data updates and visibility to everyone using it.

It also allows users to review notes and identify queries and questions noted in each record.

When a CDI program is underpinned with dedicated software, the integrity of patient records is immediately obvious – allowing the coder to identify the history and accuracy of each record. This high level of information visibility further enhances CDIs ‘first time right’ approach. 

That’s because the software will guide the process, in which:

  • Reviews are first conducted by the CDS with the treating clinician or head of the unit
  • The coders are presented with a complete picture of the report and know immediately which elements they need to question
  • Once the record has been reviewed by the CDS, all queries and clinician responses are updated within the medical record – ready for the coder to commence coding
  • Real-time data flow and a single source of truth means that there is no lag in updates for multiple users
  • Coders can get on with coding rather than spending time chasing answers.

All in all, we believe that the faster turnaround, higher rate of accuracy and improved reimbursement that hospitals gain can more than cover the cost of implementing a CDI process, CDS and coding software – particularly over time. We further believe that this advancement will become a major draw card for attracting the best talent in the field. 

For a no-obligation demonstration of how Code Focus can answer your unique coding and auditing problems, contact Callum Haggerty
at Data Agility


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