Influence of New Payment System on Clinical Documentation Management: Focus on Health Information Managers' Perceptions

Abstract

This study purpose is to investigate the influence of the New-Diagnosis Related-Groups (NDRG) system on the improvement of clinical documentation management quality, by focus on health information managers (HIMs) perceptions. Major survey questions focused on changes in the recording and management of clinical documentation due to the NDRG, experience of conflicts among stakeholders, and improvement. A survey was conducted among 237 HIMs with experience in the NDRG. The 110 completed surveys were analyzed using univariate statistics and logistic regression. Regarding changes in clinical documentation, it was noted that great importance was assigned to clinical documentation under the NDRG system (96.4%). but clinical records management workload was believed to have increased (98.2%). Communication with physicians was considered to be utmost important for improving the quality of clinical documentation in NDRG (83.8%), while conflict between HIMs and physicians was considered the most serious problem (92.7%). HIMs thought positively about the establishment of the NDRG system (75.5%). NDRG have been positive changes in clinical documentation recording, based on the diagnosis. Communication between stakeholders is important, periodic education is necessary to implement this. Appropriate workforce of HIMs should be established to improve the quality of clinical documentation and accurate coding.