Clinical documentation often does not reflect the care physicians actually deliver. The consequences are heavy: quality scores suffer, physicians don't get credit for the complexity of care they provide, and providers are flooded with reactive queries from CDI teams.

This was the reality facing a non-profit, three-hospital system in North Carolina — and its transformation offers a roadmap for health systems nationwide. By partnering with Regard to implement Proactive Documentation, the system improved quality metrics, enhanced provider well-being, and generated millions in financial impact, all without adding to physician burden.

Key results (over an eight-month period)

• $4.5M in estimated reimbursement impact, including a 3.6% lift in CC/MCC capture and $871K in MS-DRG upgrades
• $9.3M in denials prevented
• Lowest observed-to-expected mortality in the system's history for key conditions — a 22.6% improvement in sepsis and 31.3% in stroke
• Reversed a post-COVID case mix index decline to surpass peer averages
• Hospitalists saved close to 2 hours daily for patient care

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The challenge

Healthcare leaders at this three-hospital system faced the case for change head-on: clinical documentation was inconsistent and inaccurate. Quality scores were suffering. Most critically, physicians weren't getting credit for the complexity of care they delivered every day, and providers were being overwhelmed with reactive queries from CDI teams trying to improve documentation after care had already been delivered.

They identified a troubling disparity: their patients with poorer outcomes appeared less ill on paper compared to similar patients at peer organizations. The problem wasn't the care quality — it was the documentation.

Without accurately capturing severity of illness (SOI), risk of mortality (ROM), and comorbidities (CC/MCC), peer hospitals appeared to outperform them in quality rankings despite comparable care. The result was lower-than-deserved reimbursement and mounting claim denials. The health system needed a solution that would credit providers for care complexity without adding to their administrative burden.

The solution

The health system chose Regard because it enables real-time capture of diagnostic details, crediting providers for care complexity without creating burden. Unlike reactive chart reviews and CDI queries after the fact, Regard reviews 100% of chart and conversation data, recommends diagnoses with clinically relevant evidence, and generates drafts at or before the point of care.

How Regard works

• Review. Regard analyzes the entire medical record for every patient automatically.
• Insights. Regard recommends missed diagnoses and clinical details backed by evidence.
• Drafts. Regard generates documentation before the physician sees the patient and updates it in real time.

How Regard improves quality metrics

• Ensures case mix index accurately reflects patient populations
• Improves patient SOI and ROM
• Increases CC/MCC capture

Implementation: leadership, training, and early ROI

The health system's success hinged on strategic planning, thoughtful change management, and clear leadership mandates — not just technology. Regard provided personalized one-on-one training for hospitalists, established a physician advisor program to drive engagement, and enabled real-time documentation metrics per provider. Physician feedback guided workflow integration, proving ROI early while ensuring clinical adoption.

Measures of success

• Financial impact: DRG upgrades through improved CC/MCC capture, reduction in queries, and improved denial rates
• Documentation specificity: improvement in CMI, SOI, and ROM
• Patient care and safety: geometric mean length of stay, observed-to-expected length of stay and mortality, and patient safety events such as healthcare-associated infections and medication errors

The results

The shift delivered results across quality metrics, provider well-being, and financial outcomes. During an eight-month period, the health system achieved its lowest observed-to-expected mortality in history for key conditions — a 22.6% improvement in sepsis and 31.3% in stroke — and reversed its post-COVID CMI decline to surpass peer averages. Hospitalists saved close to two hours daily for patient care.

The financial impact: $4.5M in estimated reimbursement, driven by a 3.6% lift in CC/MCC capture and $871K in MS-DRG upgrades, plus $9.3M in denials prevented — finally crediting providers for the complexity of care delivered.

In conclusion

Through its partnership with Regard, the health system learned that ensuring physicians get credit for the care they deliver requires:

1. Establishing clear expectations for daily Proactive Documentation use — making it a priority, not an option.
2. Proving ROI early through real-time analytics that demonstrate immediate value, not retrospective performance tracking.
3. Partnering with vendors who provide one-on-one training and seamless clinical integration, not just administrative tools.
4. Maintaining ongoing feedback to ensure sustained workflow alignment and physician satisfaction throughout implementation.

The success with hospitalists is just the beginning. The health system is expanding Regard to additional service lines and enhancing back-end CDI workflows, moving the entire organization from reactive to proactive documentation. The goal: ensure every physician gets appropriate credit for care complexity while protecting revenue that supports continued investment in patient care.

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