Documentation capture

Navigating shifting regulations now a priority for CMIOs

Navigating shifting regulations now a priority for CMIOs

Now, more than ever, CMIOs need to keep up with new regulations in a rapidly shifting healthcare landscape. This goes beyond communicating changing regulations across the different teams within their organizations. Today, they must also put AI-powered tools and technologies directly in the workflow of frontline providers to alleviate administrative burdens and support interoperability, billing, coding and patient documentation compliance requirements.

At the recent Health Management Academy’s (HMA) Chief Medical Information Officers (CMIO) meeting, a good portion of the discussion centered on the changing landscape of regulations and even more changes from CMS and ONC that are on the horizon.

So, what changes are forthcoming? How do we keep up as an industry, and where do CMIOs fit in this shifting landscape?

The big changes are:

  1. a stronger push to interoperability
  2. a mandate for transparency by requiring notes and labs released to patients essentially in real-time
  3. rewriting coding and billing rules to focus more on time spent and medical decision making rather than documenting a required number of background elements.

All of these require changes to how EHRs function, connect between one another, transfer data, and protect patient privacy, as well as how providers document.

Most notably, by 2022, the CMS is stating the risk adjustment and related analysis of quality be drawn from what is in the provider’s notes and not by attestations or programmatic submissions. In other words, it will become crucial that all elements and specificities of a patient’s medical condition are entered into the chart as diagnostic assessments. The attendant medical decision making in the plan then must document the monitoring, evaluation, assessment needs, and treatments for each of those problems.

As the complexity of modern medicine grows and the challenges of managing patients with comorbidities and multisystem disease multiply, CMIOs will need to arm frontline providers within workflow real-time tools supported by artificial intelligence. There are just too many variables and often little time to pore over mountains of data to test hypotheses and draw conclusions. Now, more than ever, advanced computational constructs and neural networks will have to be in place to support documentation. Otherwise missed opportunities will not only impair finances and fail to meet regulatory requirements, but it will risk patient harm by missing details of medical diagnoses that beg documentation and intervention.

The future of a CMIO’s work necessitates keeping up with the many new regulations and communicating those across the different teams within their organizations—not to mention adapting workflows and technologies, and training end-users, accordingly. The combination of executive leadership and enabling technologies will allow CMIOs to operationalize innovative processes and meet regulations with the comprehensive care our patients deserve.

Robert Budman, MD MBA

About Robert Budman, MD MBA

Dr. Robert Budman, MD, MBA, and Certified Documentation Improvement Practitioner (CDIP) with AHIMA, is the Chief Medical Information Officer for Nuance Healthcare. He supports the Computer Assisted Physician Documentation (CAPD) product line and develops training and education materials for outbound and internal use. Dr. Budman is Board Certified in Family Med & Informatics. He focuses on efficiency, safety, and quality initiatives with global experience in multi-EHR and service line care delivery. His work involves implementation, workflow adoption, and optimization. Dr. Budman earned multiple clinical awards and speaks extensively on healthcare IT.