Clinical documentation is a necessary process for every hospital’s bottom line. It’s the foundation for payer reimbursement and drives the best patient care outcomes throughout the episode of care. Mistakes in clinical documentation are a real problem for hospitals and have led to millions of dollars in missed revenue.
Even when the documentation is complete, the accuracy and complexity of actual care can get lost. Small disconnects can hide clinical nuance, which means payers can quietly keep the difference. These hidden losses cost the average health system $2–$6 million per 10,000 inpatient discharges.
The source of clinical documentation starts with the physician. The purpose of this work is to document the true clinical picture of care and can put a health system at risk if done improperly.
In a 2013 paper, Adele L. Towers, MD, MPH, said, “Physicians are not taught how to complete the documentation to accurately assign codes, and physician billing does not require a high degree of specificity…however, the lack of specificity on a hospital record can affect payment. The key is to engage physicians to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided.”
While this is an important aspect for any hospital, for the physician, the most common response to why a physician may feel the effects of burnout is that they are buried in administrative processes and tasks. Physician burnout is a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations.
According to the AMA, “Physician burnout is costing the U.S. about $4.6 billion annually when you conservatively estimate the costs related to physician turnover and reduced clinical hours.”
However, in the age of AI technology, physician burnout and its related costs can be significantly reduced. Clinically driven AI engines redefine documentation by combining expert judgement with machine precision to deliver a more accurate picture of care.
Physician-led AI has the ability to analyze every chart to surface clinical signals, codable clues, and missed opportunities where clinical reality is most often lost in translation between medicine and coding. Put simply, these AI engines reveal where clinical reality isn’t fully reflected in the coded record.
AI finds the signals, interprets the complexity, and revenue cycle teams sustain the results.
AI technology does not ask physicians to document more — on the contrary, it helps reduce administrative burden and empowers physicians. Through transparent updates and trend-based education, AI reduces unnecessary queries over time and makes remaining queries more clinically meaningful. The result is a final coded record that accurately reflects the actual care delivered.
The strength of a physician’s clinical documentation not only helps ensure that a hospital will be reimbursed for the accurate clinical scenario, but it also benefits the health of the patient beyond the encounter in which it was made. Physician education in AI clinical documentation is critical to realizing better health outcomes and hospital performance.
Learn more about Amplifi, Accuity’s customized, physician-led documentation program.