Data drives decision making in health care. Computerized physician order entry (CPOE) is increasingly common in health care settings and is proven to improve health care peformance. CPOE helps to increase the quality of data that ends up being coded within the health care records system, resulting in better care (because it enables hospitals to extract accurate knowledge that informs everything they do). Accurate coding processes are the foundation for strong CPOE processes that result in good data.
We ensure that the data -- both coming from order entry systems and informing these systems -- is reviewed and coded accurately through our coding studies. We examine health records through our proprietary chart review process to determine how physicians and health records staff are entering data and coding diagnoseses and treatment programs in the hospital.
The process identifies specific issues such as missing information, inconsistent use of terminology, issues regarding the coding of procedures, and coding errors. We use these findings to assess the validity of the entire coding processes in the hospital through our team's chart review findings and through discussions with clinical and coding staff.
Our process provides evidence to physicians and health records staff on error rates. We help close the gaps in data quality and enable the hospital to better leverage coding strengths to improve patient care. We provide discussion based training to advance coding and clinical documentatoin capabilties at all levels.