From Documentation Quality Control to DRG-Based Cost Management: How CDSS Captures the Core of Medical Record Governance
On September 9, at the “Online Forum on Practical Implementation of CDSS Construction at China-Japan Friendship Hospital,” co-hosted by China-Japan Friendship Hospital and HealthJie, with co-organization by Huimei Technology, Ying Jiaoqian, Deputy Director of the Medical Affairs Department of China-Japan Friendship Hospital, introduced intelligent governance methods for medical record data, starting from the current status of medical record management and combining it with hospital practices.
Medical records are the original documentation of a patient’s entire diagnosis and treatment process in a hospital, reflecting the quality of care and technical proficiency, and are closely linked to medical safety. Yingqian Ying stated that medical records provide essential data for hospital quality control, teaching, scientific research, resolution of medical disputes, clinical decision-making, and the implementation of the Diagnosis-Related Groups (DRGs) payment system; thus, the importance of medical record management is self-evident.
China’s medical record management started relatively late, and its management systems, awareness, and methods remain to be improved. Ying Jiaoqian believes that the biggest problem in current medical record management is weak clinical management awareness, with insufficient understanding of the importance of medical records and standards for their documentation. “In terms of management methods, traditional medical record management processes only include terminal quality management within the ‘three-step quality management’ framework, lacking structural quality management and process management, which affects management efficiency and effectiveness.”
Ying Jiaoqian introduced that defects in medical record quality are mainly manifested in four aspects: first, incomplete completion of the medical record face sheet and issues with diagnosis selection; second, non-standardized use of medical terminology, resulting in inconsistent descriptions for the same disease; third, overly simplified progress notes, which render physicians’ diagnostic and therapeutic actions untraceable and pose potential legal risks; and fourth, incomplete information.
“Writing medical records well is a basic job responsibility of medical personnel.” Ying Jiaoqian stated that, due to factors such as excessive medical workload, the task of documenting medical records imposes a burden on clinical practice and hinders the continuous improvement of hospital medical record quality. Therefore, there is an urgent need to introduce information technology solutions to reduce the burden and enhance the quality of hospital medical record management.
“Without data-driven workflows to handle information logistics, our medical administration staff would be overwhelmed and unable to effectively support the development of clinical departments and the hospital as a whole,” said Ying Jiaoqian. Guided by this philosophy, in 2019, the Medical Administration, Clinical, and Information Technology departments of China-Japan Friendship Hospital joined forces to leverage the hospital’s specialty strengths. They implemented a Clinical Decision Support System (CDSS) for in-hospital risk prediction and management of venous thromboembolism (VTE). Building on these successful outcomes, the hospital further collaborated with Huimei Technology to develop a medical record quality control system, thereby ensuring rigorous management of medical record data at its source.
Reengineering Medical Record Management Processes with CDSS: The primary principle is real-time quality monitoring of clinical documentation. The second principle is automation, encompassing automatic data validation and defect alerts, as well as seamlessly enabling online interaction between clinicians and medical record staff. The third principle is efficiency, aimed at enhancing the user-friendliness of clinical interactions. Ying Jiaoqian introduced that the CDSS management workflow also features a “Three-Step Quality Management” framework. The top-level design, which integrates with all hospital business systems, constitutes structural quality management. The utilization and processing of data from various systems are referred to as process quality control. Clinical alerts represent the output of data application, corresponding to terminal quality management.
The CDSS executes quality control pathways based on data quality control rules. Therefore, prior to system deployment, it is essential to design data quality control rules starting from the standardization and normalization requirements for medical record documentation. “Taking the discharge diagnosis on the medical record face sheet as an example, the determination of the principal diagnosis follows the ‘Three Mosts’ principle, which refers to the disease diagnosis that poses the greatest threat to the patient’s health, consumes the most medical resources, and results in the longest hospital stay during the hospitalization,” explained Ying Jiaoqian. Under the “Three Mosts” principle, the principal diagnosis in obstetrics refers to the major obstetric complications or comorbidities; accordingly, the system has been designed with a quality control rule stating that “the principal diagnosis in obstetrics should be selected from obstetric complications or comorbidities.”
According to Ying Jiaoqian, China-Japan Friendship Hospital has fully implemented a medical record quality control system across the entire institution. As clinicians document medical records, the system performs multi-dimensional checks for quality defects—covering both “form” and “substance”—based on patients’ diagnosis and treatment information, standardized documentation requirements, and medical logic, prompting physicians to complete and revise their records accordingly. “Formal quality control primarily identifies incomplete fields, while substantive quality control examines logical consistency. For example, if a patient’s admission record states ‘splenectomy’ in the past medical history but ‘denies surgical history’ in the surgical history section, the system will flag this contradiction.” Through such multi-dimensional validation, along with comparisons between manual reviews by quality control staff and automated system outputs, the hospital has improved the completeness and accuracy of medical record data, as well as the standardization of diagnostic descriptions and principal diagnosis selection.
After three months of applying a Clinical Decision Support System (CDSS) for medical record quality control, China-Japan Friendship Hospital observed an upward trend in the overall adoption rate of system alerts by clinicians. Meanwhile, the total number of documentation defects and the average number of defects per medical record in clinical departments gradually decreased. “The benefits are twofold: first, clinicians’ practices become more standardized; second, medical record management becomes more refined and process-oriented,” stated Ying Jiaoqian. The hospital-wide unified quality control standards not only promote homogenization of internal quality control efforts but also enable administrators to monitor the status of medical record management in real time through multi-dimensional quality control data aggregation provided by the system.
"The DRG-based payment system is being comprehensively implemented, making diagnosis-related group (DRG) assignment and coding selection critical challenges for hospitals. 'Taking DRG grouping as an example, under-coding, up-coding, or missed coding can all expose hospitals to performance penalties and financial losses,' stated Ying Jiaoqian. Building on standardized medical record data, hospitals will collaborate with Huimei Technology to advance quality control applications in DRG management, thereby facilitating reasonable cost containment at the hospital level."
DRG management encompasses diagnostic grouping, hospital performance management, and medical cost forecasting. The system alerts physicians to the current case’s DRG assignment and the correct diagnostic grouping while they are documenting medical records. It also provides warnings regarding risks such as low-risk mortality, excessive costs, and prolonged length of stay. This functionality aims to improve DRG assignment accuracy and reduce economic losses stemming from diagnostic grouping errors. Hospital administrators can leverage the system’s statistical dashboard to analyze performance issues and cost patterns across various organizational levels, thereby formulating targeted improvement strategies.
“During the process of hospital management, the information department is our partner in collaboration within the Medical Affairs Office, while clinical departments are the recipients of our support. We hope to enhance the efficiency of hospital management through informatization in the future,” stated Ying Jiaoqian.
Ying Jiaoqian
Deputy Director of the Medical Affairs Department, China-Japan Friendship Hospital. Expertise in risk management in healthcare and advancing discipline construction in alignment with the hospital’s overall strategic planning. Member of the First Emergency Surgery Professional Committee of the Emergency Physicians Branch of the Chinese Medical Doctor Association; Member of the Third National Rescue Collaboration Study Group of the Emergency Resuscitation Professional Committee of the Chinese Medical Doctor Association; Youth Editorial Board Member of Chinese Health Quality Management; Member of the First Medical Affairs Study Group of the Medical Quality Management Professional Committee of the Chinese Hospital Association; Member of the Beijing Outpatient Medical Quality Control and Improvement Center; Certified International Senior Vocational Trainer by the American Certification Institute.