Modern health systems face a significant Clinical Insights Gap that compromises patient safety, hinders revenue integrity, and contributes to physician burnout. Recognizing this challenge, a five-hospital integrated health system serving South Dakota and Wyoming partnered with Regard to rebuild its clinical documentation workflows — empowering physicians to produce accurate, comprehensive documentation that promotes high-quality care, prevents automatic denials, and enhances revenue capture.

Key results

• 41.7% improvement in Elixhauser capture
• 33.8% improvement in CC/MCC capture
• $558,000 in new revenue from MS-DRG upgrades
• $708,000 protected from automatic denials

Download the full solutions brief »

The challenge

With over 50,000 data points in each patient's electronic medical record, physicians couldn't possibly dig into every piece of information. But the pressure to do so was real. One test result or diagnosis buried within the documentation could change an entire treatment plan and patient outcome.

The same was true for reimbursement. A single complication or comorbidity (CC) or major CC (MCC) could shift an entire MS-DRG. And for cases with only one CC or MCC, adding an additional one could prevent an automatic denial.

Over time, the push to fix non-standardized, incomplete documentation drove physician query rates up — pulling physicians away from direct patient care. As physicians continued to comb through each medical record by hand, burnout rates climbed. Leaders knew that patient safety, physician retention, and reimbursement were all at risk.

The health system needed a solution that would reduce the burden on clinicians, standardize accurate and complete documentation, and surface important clinical insights at the point of care.

The solution

The health system chose to partner with Regard, which transforms patient data into actionable insights that support better patient care and accurate reimbursement.

How Regard works

• Review. Regard reviews the entire medical record for every patient.
• Diagnose. Regard catches errors and recommends diagnoses to ensure a complete patient view.
• Proactive Documentation. Regard provides a complete first draft of documentation before the physician sees the patient and keeps it up to date in real time.

Implementation built on change management

Prior to kick-off, health system leaders primed clinical teams for engagement by focusing on change management and how the technology would improve physician workflows.

Next, Regard's implementation team shadowed hospitalists and ICU physicians to understand current workflows, attended hospitalist department meetings to demonstrate new workflows and address questions, and met with clinical leadership to define key performance indicators and how the organization would measure return on investment.

Measures of success

• Financial impact: per-patient reimbursement, DRG upgrades, revenue protection, and denial rate
• Documentation specificity: CC/MCC capture rate, case mix index, severity of illness, and risk of mortality
• Patient care and safety: observed-to-expected length of stay, readmissions, patient satisfaction, and patient safety events such as hospital-acquired conditions and medication errors

Clinician training ran in two steps. Regard's implementation team first trained five users, including the health system's medical director, who served as a champion for the technology. It then rolled training out to additional clinicians with onsite, one-on-one education — and extra time for anyone who needed it. Regard continues to evolve the technology based on user feedback to ensure it meets clinicians' needs.

The role of physician champions

Champions did three things that made the rollout stick: they built excitement among clinical teams, funneled user feedback back into the product, and helped colleagues understand the workflow adjustments.

The results

At the conclusion of the pilot program, Regard improved documentation quality and increased revenue while enhancing physician satisfaction and reducing burnout:

• 41.7% improvement in Elixhauser capture
• 33.8% improvement in CC/MCC capture
• $558,000 in new revenue from MS-DRG upgrades
• $708,000 protected from automatic denials

In conclusion

Through its partnership with Regard, the health system learned it must take four steps to achieve clinician buy-in for long-term success:

1. Devise a strong change management strategy.
2. Identify and leverage physician champions.
3. Partner with a vendor that understands clinical workflows and provides customized physician training.
4. Provide ongoing user feedback to drive product improvements.

As the health system looks ahead, it is expanding use of the platform by codeveloping other services and extending the Clinical Insights platform into its ICU.

Download the full solutions brief »

Ready to see how Proactive Documentation enhances patient care and protects hospital revenue? Request a demo