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"How a North Carolina health system transformed clinical documentation to ensure revenue integrity"

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.

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. Providers were being overwhelmed with reactive queries from CDI teams, and 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. 

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