Cleveland system keeps up with computer-assisted coding, documentation improvement
The Cleveland Clinic Health System (CCHS) is successfully evolving, using computer-assisted coding (CAC) to address clinical documentation improvement, ICD-10 implementation and more, according to an article published in the July issue of Journal of AHIMA.
Changes in the health information management (HIM) landscape and increasing demands “set the stage for alternative solutions. Electronic health records and CAC can be leveraged to automate and improve documentation, coding, data extraction and ultimately patient care. At CCHS, we view this changing landscape as an opportunity for innovation and transformation,” the authors wrote.
After required publicly recorded quality measures showed CCHS trailing similar academic centers, stakeholders initiated an enterprise committee that aligned key leaders in clinical care, finance and quality. Named the Documentation Extraction Reporting and Transformation (DERT) committee, the team originated an innovative model to transform documentation and extraction practices to positively affect patient care, data integrity, documentation, clinical coding and financial performance.
“One of the lessons our organization learned, specifically for the HIM professionals, is that they are the frontline of quality and safety relating to reimbursement and reputation. As caregivers, we eagerly accept the role of stewards of data integrity,” according to the article.
The CAC implementation provided several benefits including a “search and compare” function that assists coders and clinical documentation improvement staff in reviewing vast amounts of data more efficiently, querying edits effectively and increasing capture of patient severity. This improved coder and CDI staff satisfaction.
Technology tools such as CAC were an integral part of the plan to improve documentation and data integrity, and to address the transition to ICD-10. CCHS plans to expand its use of the CAC product, “to continually improve the quality of patient care and its translation through coding.”
Changes in the health information management (HIM) landscape and increasing demands “set the stage for alternative solutions. Electronic health records and CAC can be leveraged to automate and improve documentation, coding, data extraction and ultimately patient care. At CCHS, we view this changing landscape as an opportunity for innovation and transformation,” the authors wrote.
After required publicly recorded quality measures showed CCHS trailing similar academic centers, stakeholders initiated an enterprise committee that aligned key leaders in clinical care, finance and quality. Named the Documentation Extraction Reporting and Transformation (DERT) committee, the team originated an innovative model to transform documentation and extraction practices to positively affect patient care, data integrity, documentation, clinical coding and financial performance.
“One of the lessons our organization learned, specifically for the HIM professionals, is that they are the frontline of quality and safety relating to reimbursement and reputation. As caregivers, we eagerly accept the role of stewards of data integrity,” according to the article.
The CAC implementation provided several benefits including a “search and compare” function that assists coders and clinical documentation improvement staff in reviewing vast amounts of data more efficiently, querying edits effectively and increasing capture of patient severity. This improved coder and CDI staff satisfaction.
Technology tools such as CAC were an integral part of the plan to improve documentation and data integrity, and to address the transition to ICD-10. CCHS plans to expand its use of the CAC product, “to continually improve the quality of patient care and its translation through coding.”
Beth Walsh,
Editor
Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.