Reducing Hospital Costs with Improved Clinical Documentation Management

Reducing Hospital Costs with Improved Clinical Documentation Management

Author -  Winscribe

As of April 2015, 98 percent of all hospitals and 95 percent of Critical Access and small rural hospitals have demonstrated meaningful use and/or adopted, implemented or upgraded (AIU) any EHR.  But while adoption is at an all-time high, so are hospital costs.

In an effort to achieve revenue gains, some hospitals have turned to improving clinical documentation.  Improving the way documentation is created, processed and managed and putting in place a clinical documentation improvement program is a strategy that can lead to long-term financial stability say supporters.

Clinical Documentation Improvement (CDI) programs can directly drive revenue cycle management. As well, these initiatives fuel correct reimbursement and accurate quality reporting. Still a myriad of people, processes and technology must work together to ensure CDI programs meet these goals. Clinical documentation improvement initiatives must also work in a way that not only eliminates the risk of lost revenue, but also creates minimal impact on the clinicians working on the front lines with patients.

The Negative Impacts of Poor Quality Documentation

Poor documentation is one of the greatest threats to a hospital’s revenue integrity. Some negative impacts of poor documentation include:

  • Coding, reimbursement and case mix are negatively impacted when documentation is missing, unclear or insufficient
  • Quality scores could be falsely reported due to improper documentation
  • Patient care can be adversely impacted
  • Malpractice and liability risks
  • Additional costs may be incurred for repeat tests/exams

Hybrid Documentation Enhances Clinical Documentation

Physicians time is better spent on patient care than as a resource for data-entry tasks. By pairing EHR data management with speech productivity and workflow management solutions, hospitals can reduce their overall operating costs. Implementing strong, physician-focused documentation tools, like dictation and speech recognition, as part of a clinical documentation improvement plan, is an efficient way to improve physician clinical documentation. With intelligent speech technologies and customized templates, hospitals can positively impact their documentation processes.

Advantages include:

  • Enabling the transition from volume to value based healthcare initiatives
  • Returning time back to clinicians 
  • Improved patient records and care
  • Making the EHR documentation experience better
  • Better documentation for coding and billing purposes and increased cost savings

See the Recorded Webinar: “Improving Hospital Revenue Through Better Clinical Documentation”

View our recorded webinar from December, 2015 to learn more about:

  • Best practices for improving clinical documentation
  • Clinical documentation methods, turnaround time and management effects on profitability
  • The importance of maintaining higher levels of documentation specificity and accuracy to improve hospital revenue
  • How hospitals can leverage clinical documentation software to improve documentation and receive a fast ROI



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