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

AbstractThis study purpose is to investigate the influence of the New-Diagnosis Related-Groups (NDRG) system onthe improvement of clinical documentation management quality, by focus on health informationmanagers (HIMs) perceptions. Major survey questions focused on changes in the recording andmanagement 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 110completed surveys were analyzed using univariate statistics and logistic regression. Regarding changesin clinical documentation, it was noted that great importance was assigned to clinical documentationunder the NDRG system (96.4%). but clinical records management workload was believed to haveincreased (98.2%). Communication with physicians was considered to be utmost important for improvingthe quality of clinical documentation in NDRG (83.8%), while conflict between HIMs and physicians wasconsidered the most serious problem (92.7%). HIMs thought positively about the establishment of theNDRG system (75.5%). NDRG have been positive changes in clinical documentation recording, based onthe diagnosis. Communication between stakeholders is important, periodic education is necessary toimplement this. Appropriate workforce of HIMs should be established to improve the quality of clinicaldocumentation and accurate coding.