How technology can assist in achieving higher quality clinical coding
Hospital information systems in Australia currently face multiple challenges that affect the reliability and timeliness of clinical coding. From incomplete clinical documentation and inconsistent terminology to difficulty in keeping up with coding quota and revised coding guidelines, many health information managers and clinical coders are facing challenges in achieving quality clinical coding outcomes.
Fortunately, new technologies have emerged over the years offering opportunities for significant improvements in the quality and efficiency of our hospital information systems. These technologies aim to help Health Information Services teams to:
- Achieve greater reliability in clinical coding
- Reduce complexity on behalf of clinical coders
- Ensure correct revenue
- Support coder education
- Build efficiency in health care delivery
Let’s look at the individual technologies and their benefits in more detail.
Electronic health records
Their key benefits to all aspects of health information systems
Electronic Health Records or EHRs are real-time patient-centered records. These EHRs give authorised persons easily accessible information about a patient that may also include medical history and the compendium of treatments they’ve received. Along with all standard data, EHRs are more extensive and provide a wider overview of a patient’s health and care.
EHRs have become a crucial factor in improved patient care and coordination, increased patient participation, improved diagnostics and patient outcomes. Other benefits include more reliable prescriptions, higher effectiveness in diagnoses, reduced medical errors and safer patient care in general, not to mention heightened privacy protection for patients. This also allows for convenience as patients and healthcare providers can access information remotely.
Electronic health records have impacted clinical coding efficiency and reliability in many hospital’s information systems as well. Having reliable, up to date and complete information for patients goes hand-in-hand with services that organisations like Code Focus offers. By having access and ability to gather more clear-cut information and exact data, the auditing process becomes increasingly precise.
EHRs are extremely valuable for clinical coders and hospital IT departments as they raise levels of flexibility. Through these digital records there is an opportunity to raise exactitude in coding because of better clarity and legibility. Accessibility also benefits them because they are able to work with information immediately instead of waiting for paper-based documents.
In a nutshell, by implementing the use of electronic health records, we can expect:
- More extensive information to provide excellent patient care
- Better implementation of workflow and distribution of all resources.
- An increase of reliability in records and clinical coding
- Accessibility and readability for coders
Improving workforce and workflow efficiency
Many hospitals are also starting to invest in auditing tools to improve their workforce efficiency, as they offer a quality assurance process as well as an educational opportunity for coders.
Auditing tools provide insights into the process of coding itself, automatically flagging episodes of interest to audit. Health information managers can determine how and why a particular code was or was not selected, helping them ensure their coding is always aligned with specific guidelines.
Unlike traditional auditing methods, auditing tools are not bound to the levels of human expertise nor subjected to high error rates. These features enable them to better detect errors and identify the root cause of coding and documentation discrepancies.
For instance, Code Focus which is a real-time auditing tool, allows Health Information Service teams to create their own audit rules to target specific coding errors. Code Focus also enables them to flag medical record deficiencies and clinical documentation integrity issues in one centralised location. All these capabilities ensure coding standards are applied at all times. This results in high-quality coding and insights that both executives and Health Information Managers can use to assess their hospital’s workforce and financial performance.
By enhancing the clinical coding improvement of hospitals, auditing tools help healthcare organisations ensure:
- Proper policies and procedures are in place to achieve quality medical coding
- Proper reimbursements are obtained and there are no leakage in funds
- Regulatory compliance is maintained
- High standards of coding quality and reduce the risk of lost or misdirected revenue
Choosing the right technology
Harnessing the right tools to enhance code quality
Getting the right health information technology could mean a significant improvement in the quality and effectiveness of your health care. They not only help reduce costs and business risks but can also save you time on managing daily operations so you can focus more on patient treatment and health.
There are more technologies out there that can help you improve the quality of your clinical coding.
Finally, remember that the best health information technology should always:
- Meet the best practices for clinical coding
- Support effective clinical communication
- Drive the quality and efficiency of your healthcare delivery
- Support your workforce in their roles
Want to learn more about how you can improve your clinical coding, and ensure correct revenue and workforce efficiency? Get real-time access to your clinical coding and auditing data. Book a demo today to learn more about how Code Focus works.