By Megan Williams, contributing writer
The organizational impact of EHR (electronic health record) systems on your clients is possibly best managed and improved through refining the content of the records itself. With ICD-10 looming, this fine-tuning process is becoming even more important in aligning EHR performance with organizational goals. Clinical data integrity (CDI) is the bridge between the EHR and the metrics your clients find most important on a daily basis.
According to Health IT Analytics, here are some ways CDI plays into some of your clients’ most pressing concerns.
Pushing CDI to the front burner has helped many organizations get better physician buy-in to the overall data process. While some might balk at ICD-10 overall, most will understand that better, more accurate data is important — this is why some programs have resorted to more “creative” methods and dropped the emphasis on ICD-10 altogether.
Dr. Georges Feghali, Chief Medical Officer and Chief Quality Officer at Ohio’s TriHealth Medical sums it up: “As a physician, I don’t want too many things when it comes to documentation.” He adds, “Don’t make me lie; don’t make me do it for financial purposes. Tell me why we do it, and I will change the behavior. I don’t think there’s a physician on earth who is going to say, ‘I don’t care how I look, so I’m going to keep writing it the wrong way.’”
Organizational Information Governance
Data governance is a topic that’s bound to be on the minds of any healthcare organizational leader. If they want to establish a strong CDI initiative, data governance must come first — it is the foundation of any healthy approach to addressing data within healthcare organizations.
Analytics overall has moved to a focus on structured data, to using technologies like natural language processing (NLP) to make better use of unstructured data. Still, patient records are left with gaps that go beyond anything technology can pick up.
Mel Tully, MSN, CCDS, CDIP and VP of clinical services and education at Nuance says, “I’ve been doing CDI for 15 years and physicians still don’t provide all the details needed to ensure appropriate, thorough documentation. Unless they’re being prompted and given a tool or person to help guide them, they will always document pneumonia as pneumonia. There are many, many other ways to document it and even today, physicians still need guidance on how best to capture the specific details needed to accurately reflect the severity of the care provided.”
Improving Quality Measurement For Accountable Care And Reporting
And of course, data integrity has a pronounced impact when trying to measure cost and efficiency. In an environment where pay-for-performance reimbursement is becoming more common, and ACOs are at the forefront of new healthcare delivery models, the value of CDI is always increasing.
It is important to remember to connect the EHR and data integrity services you offer overtly with client needs. Use this list in your sales process and customer communications as a reminder of the true benefit you bring along with you.