Remember the last time you created a file at work that didn’t save properly, and you lost hours of effort. How did you feel? You were probably frustrated, and it may have stopped you from finishing something important. But it wasn’t life or death.
Now imagine the consequences when clinical documentation is lost, corrupted, or damaged. These documents contain sensitive medical information that affects how your doctor diagnoses you and the medications they prescribe to you. In contrast to your missing work file, errors with clinical documentation can be deadly. The worst part is that these issues are preventable.
What do healthcare providers need to do to prevent this from happening?
How software helps you improve and protect clinical documentation
The modern physician’s oath requires physicians to promise that they will provide the best care they possibly can, treat patients with compassion, and respect patient privacy. Fulfilling this oath isn’t always easy, but the best physicians continually work at it.
Clinical documentation improvement (CDI) software is one of the most powerful tools for meeting these standards. CDI software improves the quality of documentation and the speed at which physicians can treat patients, and it increases revenue. Let’s look at these benefits one by one:
- CDI software improves the quality of documentation. There has often been controversy as to how many people die each year due to preventable medical errors. While a 1999–2000 study put the number of deaths between 44,000 and 98,000 in the U.S., a 2016 study estimated that it was more than 250,000. Whatever the exact number, it’s unacceptable. CDI software helps medical organizations standardize medical coding terminology, which improves the accuracy of patient records so that the severity of a patient’s illness and the complexity of their care are clear.
- CDI software improves the speed of treatment. Coding errors and miscommunication cause misdiagnosis and the prescription of unhelpful or even harmful medication. By reducing the number of communication errors through CDI software and training, physicians can get to the right solutions quicker. Enhanced communication improves the efficiency of physician care, ultimately allowing doctors to see more patients and increase revenue for their organization.
- Increase revenue for the medical organization. Increasing the speed of treatment allows physicians to see more patients, but there are also financial benefits to CDI software. These include less revenue lost because of messy record-keeping, more referrals due to a higher quality rating, and increased automation.
The right technology is crucial to building an efficient, high-quality medical organization. But where do healthcare organizations start? Let’s review three of the best software solutions.
Three CDI software solutions that stand out
- 3M™ 360 Encompass™ System is much more than a typical CDI. It’s an all-in-one solution that combines computer-assisted clinical and physician documentation, coding, and quality management services. 3M’s system is designed to help hospitals reduce duplicate work, promote compliance, and ensure accurate reimbursement.
Who it’s for: healthcare organizations looking to standardize coding and documentation, capture more reimbursements, and fix a fragmented system
- Nuance CDE (clinical document excellence) is a cloud solution that focuses on documentation while providing collaboration and scalability. Nuance uses AI software to help physicians gather patient information and avoid duplicating their work. Nuance’s long tenure in the medical field gives them an extensive knowledge base they can leverage when supporting a healthcare organization.
Who it’s for: healthcare providers who want a cloud solution that fosters team collaboration and automates portions of the documentation process
- ChartWise’s CDI provides expert help while conforming to an organization’s needs. ChartWise’s software includes a knowledge base that can provide physicians with recommendations based on a patient’s chart. They support the organization’s current workflow and can quickly adapt to change.
Who it’s for: organizations seeking a tool that supports clinical documentation specialists, health information managers, administrators, or physicians
Increase revenue and improve efficiency before financial troubles hit
Preventable errors are bad for the organization, the bottom line, and team morale. CDI technology can help streamline coding and documentation as well as the sharing of information. Don’t wait for a crisis. The best time to make a change is when things are going well.
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