Clinical Documentation Improvement Framework for the Private Sector in the Kingdom of Saudi Arabia

Fawaz Alomran ^a, Susan Young ^a, Wail Yar ^a, Simone Gravesande-Joseph ^b, Eric Evenson ^b

Introduction
As part of Vision 2030's healthcare transformation goals, the private health sector in Saudi Arabia is implementing new and innovative ways toward more transparency in healthcare financing and provision such as National Platform for Health Information Exchange Services (NPHIES), Saudi Billing System (SBS), Minimum Data Set (MDS) and AR-DRGs (Australian Refined Diagnosis Related Groups.) The Council of Health Insurance (CHI) has completed several strategic initiatives aimed at understanding and enhancing the quality of clinical documentation and coding in the private sector in a fair and transparent way. The main goals of these projects have been to 1) engage the private health care providers in improving the efficiency and quality of data through accurate and complete documentation and 2) enhance data and quality outcome transparency and allocate resources efficiently to achieve high-quality healthcare.

Methods
CHI completed a comprehensive evaluation of the current state of clinical documentation, in the private sector. This review included onsite interviews, workflow observations, and a clinical documentation improvement (CDI) audit of five hospitals. CHI also completed an international literature review of CDI best practices, guidelines, and a gap analysis against these best practices with the current state. Additionally, insurance claims were reviewed as well as the minimum data set requirements for providers to submit insurance claims to understand which data fields are currently being collected.

Results
A comprehensive Clinical Documentation Improvement framework was created along with an implementation and engagement plan with the private providers. Each of the hospitals that participated in the initial review and audit received custom summary of their results with recommendations. Aggregate results and observations have been shared with the private sector.

Discussion/Conclusions
We will review best practices and lessons learned for how a healthcare regulator, insurer and provider can begin to establish and implement clinical documentation improvement standards in an emerging market.


^a Council of Health Insurance, Saudi Arabia
^b Solventum, United States

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