The Importance of Capturing the True Clinical Picture

The following is a guest blog post by Geoff New, MBA, RHIA, CRCR, Vice President of Provider Solutions at Ciox.

To say that health information management (HIM) has changed is an understatement. From a paper-based system of recording medical encounters to today’s widespread use of technology, analytics, and artificial intelligence, the role of an HIM professional continues to evolve. However, the core of HIM –  the data collected in medical records – remains constant, making the accuracy and integrity of that data paramount to ensuring health care quality.

EMRs and Aggregators Bring Challenges

With the utilization of electronic medical records and the introduction of multiple systems that overlap organizations and providers, managing health information has become more complex and is not without some risks. As data from medical records are collected, omissions, errors and incomplete documentation can be magnified by the various creators, systems, and aggregators. This in turn can affect the patients, providers, facilities and other users of that data. Therefore, it is more important than ever that HIM professionals provide proper documentation and eliminate erroneous data to reflect the True Clinical Picture.

A Solid Foundation is Important to Any Structure

Solid documentation serves as the clinical foundation for health care organizations. Medical records are the primary vehicle for communicating essential information about the patient’s diagnosis, treatment and outcomes.  Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. It’s the job of HIM professionals to find all the pieces and assemble them to illustrate the full picture of a patient’s care.

Improve Clinical Documentation Quality, Improve Health Care

Think about a puzzle that is missing a few pieces. While you still have a sense for what the puzzle is depicting, those missing pieces may include critical elements that prevent you from visualizing the full picture. The same is true for clinical documentation. Medical records are read by clinicians, providers, payers, legal entities, consumers and many other organizations in the health care space with varying uses for the data in the records. A single missing piece may make a big difference in the story of a patient’s care, and ultimately alter a critical decision.

So, how do HIM professionals get the right pieces in place?  By ensuring the quality of the documentation within each patient record or, in other words, through Clinical Documentation Improvement (CDI). Though CDI is not a new concept for the health care industry, many providers struggle with the basic elements of documentation.

In today’s health care landscape, CDI plays a significant role in quality, leading some organizations to shift from traditional CDI programs to Clinical Documentation Quality Improvement (CDQI) programs to further solidify the content and messaging of patient documentation. CDQI goes beyond audits and reviews to ensure the correct code has been applied and finds opportunities to:

  • Improve specificity
  • Query physicians for clinical validation
  • Educate stakeholders to improve the medical record quality, not just the coding quality

CDQI is all about complete, concise and accurate documentation that provides holistic information regarding the patient’s care. The industry landscape continues to change with the call for greater transparency from providers, payers and consumers. Organizations must review current documentation and take a reactive stance toward ensuring they are ready for changes that impact their ability to provide the best care while being appropriately reimbursed for that care.

It is critical for HIM professionals to ensure that clinicians and providers understand the extent to which documentation matters. Every record represents a real person; therefore, it is imperative that every record present the True Clinical Picture.

Navigating Denials

Today, many organizations continue to struggle with managing current denials, let alone taking the next step forward into denials prevention. A combination of factors contributes to this struggle:

  • Decreases in internal staff as denials volume may be increasing
  • Multiple systems from which data must be extracted
  • Complex data that may lead to “data analysis paralysis”
  • A mixture of internal and external resources that may not be operating consistently

All these forces can lead to a vicious cycle of increasing rework without ever solving the problem of revenue leakage. So, what can be done to ensure effective denials management?

“Healthy Denials” and Complex Denial Management

Denials happen. It’s what we do with the information that determines the future success of any denials management program. Are you aware of the healthy benefits of denials? Not only do denials challenge us and make us think about why they are occurring, but they are also the best tool for achieving prevention through education. Use denials to provide education on coding, documentation and the importance of ensuring the True Clinical Picture is always captured.

The root cause of denials may seem straightforward when grouping large amounts of data. But when the items that typically contribute to denials are combined with other systemic challenges, your initial solution may not prevent denials and revenue leakage completely. A closer look reveals additional opportunities for improvement.

For example, the Master Patient Index (MPI) holds a wealth of information that supports the clinical picture, and a neglected MPI can be the foundation for many ongoing problems in the revenue cycle. Like MPI, other areas may singularly create problems for organizations, but when combined can create an increased denials rate that results in rework, lost productivity and, ultimately, lost revenue. These include:

  • Incomplete orders to support requests
  • Creation of duplicate accounts
  • Lack of documentation of symptoms and chronic conditions
  • Lack of complete, concise, coding and billing
  • Lack of documentation clarity and completeness
  • Multiple data sources without common data elements

To successfully address denials, it is crucial for clinicians and revenue cycle leaders to understand the elements that make up the True Clinical Picture and for HIM professionals to drive accuracy and integrity of the data to facilitate a positive impact on potential denials activity.

At the end of the day, everyone wins through quality – patients receive optimal care and health care providers benefit financially and operationally. Ultimately, everyone realizes the benefits that come with the availability of high-quality health information. Focusing on improving the quality of documentation and medical records allows organizations to consistently present the True Clinical Picture, facilitating meaningful use of information to achieve positive outcomes.

About Ciox
Ciox, a health technology company and proud sponsor of Healthcare IT Today, is dedicated to significantly improving U.S. health outcomes by transforming clinical data into actionable insights. Combined with an unmatched network offering ubiquitous access to healthcare data, Ciox’s expertise, relationships, technology and scale allow for the extraction of insights from structured and unstructured clinical data to create value for healthcare stakeholders. Through its HealthSource technology platform, which includes solutions for data acquisition, release of information, clinical coding, data abstraction, and analytics, Ciox helps clients securely and consistently solve the last mile challenges in clinical interoperability. Ciox improves data management and sharing by modernizing workflows and increasing the accuracy and flow of information, while providing transparency across the healthcare ecosystem and helping clients manage disparate medical records. Learn more at