Modern healthcare has become complicated in recent years. To keep up with the increasing patient inflow and complication level of diseases, healthcare billing professionals must optimize clinical workflows for maximum efficiency and output. Clinical workflows are a set of procedures and protocols that help large and small healthcare organizations complete medical and administrative tasks, ensuring their compliance with regulations. Due to their role in ensuring that all billing, administrative, and claim-related processes are carried out efficiently, clinical workflows are critical to an organization’s RCM system. This article elaborates on why clinical workflows matter in the long run and why modern healthcare systems must pay equal attention to optimizing them.

What Are Clinical Workflows?

Workflows are critical to the success of organizations as a whole. Modern healthcare is no exception. Clinical workflows are a set of time-critical tasks and actions that healthcare workers, like doctors, clinicians, billing professionals, etc., must complete to ensure the desired outcomes.

Healthcare is not just restricted to caring for patients. Revenue management and patient management are instrumental in ensuring that any given healthcare facility is run efficiently. Clinical workflows lay the foundation for efficient management of both aspects. They comprise the following details important to the revenue cycle:

1. What needs to be done? (recording patient details, taking prescriptions, capturing important information from EHRs)
2. Who performs these actions – doctors, billing professionals, mid-level practitioners, etc.
3. What tools and systems are used to support the successful implementation of workflows? For e.g,  EHRs.
4. When does it happen? (At admission, registration, post consulting with physicians, at billing)
5. Flow of information (What data is needed and when)
6. Decisions and branching points based on needs.
7. What information is needed? (patient’s medical history, current medication details, lab results, clinical notes, etc.)

Workflows enable teams to capture important information from one phase of a patient’s journey and present it wherever required, making transitions much easier. For example, when a new patient walks in, hospital administrations implement clinical workflows to capture important details that help physicians understand their medical history before beginning the diagnosis process. This paves the way for a holistic treatment approach, improving the quality of care provided to patients.

Understanding the difference between clinical guidelines and workflows:

Clinical guidelines state what is to be done, while workflows indicate how it is to be done.  For example, if a patient is diabetic, clinical guidelines state, ‘Check blood sugar levels for diabetic patients.’ Clinical workflows state:

1. Who orders the tests?
2. Where is it done?
3. How are these results recorded?
4. Who reviews them?
5. What happens if the results are abnormal?

Clinical workflows play an important role in determining how hospitals get paid. Clear, streamlined workflows can help prevent major errors from happening, thus contributing to a positive revenue flow. 

Why Clinical Workflows Are Crucial In RCM Cycles?

Clinical workflow in healthcare forms the foundation of a robust RCM system. Streamlined workflows lead to efficient and transparent billing and claim processing, ensuring a steady flow of revenue to a healthcare organization. Here is how clinical workflow in healthcare contributes to a steady RCM system.

Effective RCM Starts With Streamlined Clinical Workflows

The revenue cycle system is activated the moment a patient walks into any healthcare facility. It is important to set clear, well-defined medical workflows that are practical, categorized, and streamlined from this point on, until the patient exits the system.

Accurate Documentation Depends on  Clear Workflows

Hard claim denials are the leading cause of revenue loss in modern healthcare. To prevent it from happening, it is important to have optimized clinical workflows that capture patient data and other related details from the very first interaction between a patient and hospital. This ensures transparency and clarity in documentation, feeding accurate information to the RCM system, tightening its efficiency.

Workflows that neatly define:

1. What needs to be documented?
2. Who documents it?
3. When should it be done?

These details matter in the long run, as they help coding and billing personnel, and administrators enter appropriate data into the right resource.

Better Coding Starts With Better Clinical Workflows

When the documentation workflows are well-defined, medical coders find it easier to assign appropriate ICD-10 and CPT codes to respective diagnosis. CPT coding is an equally important aspect of any efficient RCM system, enabling hospitals to accurately list billable medical services.

Types Of Clinical Workflows

Clinical workflows are categorized based on how further tasks are performed. Depending on this factor, they are categorized into the following types.

Linear Clinical Workflows

As the name suggests, these workflows are clear and straightforward. They are easy to follow and can be used for medical procedures that do not involve a lot of complicated conditions. Something as simple as a routine vaccination falls under this category. 

Conditional Or Branching Workflows

This type of workflow requires due diligence from concerned doctors and medical personnel. In these workflows, the next steps to be taken depend on patient data or clinical findings. For example, in case of cancer patients, a treatment plan is only created based on test results.

Parallel Workflows

As per the name, parallel workflows provide directions for simultaneous medical procedures.

Iterative Workflows

Workflows that are defined for repetitive procedures that are to be performed after a certain phase.

Optimizing clinical workflows that comply with the regulatory requirements and demands of modern healthcare can be cumbersome. This is where AI and related technologies can be leveraged to create a productive feedback loop. RapidClaims RCM is powered by AI, allowing medical personnel to have a holistic view of data resources and helps them to strategize and optimize existing workflows to suit modern healthcare requirements, while also ensuring compliance with regulatory requirements.

Conclusion

Clinical workflows are critical to the smooth functioning of hospitals, now more than ever. With more and more medical emergencies and complexities coming up, healthcare facilities are resorting to AI-powered RCMs like RapidClaims to ensure accurate coding and documentation. This is an effective step towards crafting guidelines and strategizing clinical workflows that ensure steady revenue flow.

FAQs

Why is clinical workflow optimization important?

Clinical workflows are critical to the smooth running of any healthcare organization. Having a well-defined workflow ensures that patient details are captured accurately, ensuring that the right information is being fed into the RCM system, paving the way for effective care and billing processes. In addition to revenue, these workflows are an excellent source of feedback for all those involved in healthcare. With well defined workflows in existence, value-based caregiving gains traction, thereby improving overall patient care.

Are clinical workflows similar to clinical guidelines?

Clinical workflow in healthcare is different from clinical guidelines in the sense that workflows define how to go about a certain medical procedure – who to approach, what action is to be taken, at what phase it has to be taken, etc. Clinical guidelines inform concerned people about what is to be done. 

How are clinical workflows connected to Revenue Cycle Management?

Workflows define how information is stored and relayed in a system. Modern healthcare establishments are no exceptions. Clearly defined workflows ensure that billing personnel and payers get a clear understanding of the medical services that were performed during the course of a patient’s treatment. Streamlined workflows encourage positive revenue flow by bringing down the percentage of hard claim denials, improving transparency and clarity for those involved.