Most healthcare providers decided to get in their line of work because they wanted to help people. Many feel frustrated because they spend so much time on EHR documentation. A study that was performed by the American Medical Association in the year 2016 showed that for each hour a doctor spends with patients, they spend two hours on data entry and administrative tasks. Additionally, doctors spend an average of two hours each day working on data entry when they are not in the office.
Clinical documentation improvement (CDI) allows physicians to spend more time with their patients. It also helps ensure that each encounter with a patient is captured accurately. Since healthcare organizations increasingly utilize data that is more and more complex, data needs to be documented properly.
For clinical documentation improvement programs to be successful, an accurate representation of a patient needs to be created. That information will be translated into coded data. The data is then translated into public health data, quality reporting, electronic health records, reimbursement, and disease tracking and trending.
Additionally, for a healthcare provider to offer the best care to a patient, an accurate record of the patient’s health and their treatments is needed. Clinical documentation improvement CDI will ensure that all members of the healthcare team receive accurate information on a patient.
There are financial benefits that come from clinical documentation improvement. A report that was compiled in 2016 showed that hospitals that used outsource clinical documentation functions and had more than 150 beds experienced gains of over $1 million in claims reimbursements and healthcare revenue after implementing CDI. And when healthcare leaders were interviewed, over 85 percent reported that their organization saw case mix index increases and quality improvements.
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