Dr. Terrance Govender, the Vice President of Medical Affairs at ClinIntell, brings a unique perspective to the world of clinical documentation. His journey has taken him from South Africa to the United States, with a significant stop in the United Kingdom. Here, he shares his experiences and insights on clinical documentation and what excites him about his work at ClinIntell.

Why did you decide to join ClinIntell?

My journey through the medical profession in South Africa, the United Kingdom, and the United States is filled with diverse clinical experiences. In each setting, the constant was the importance of accurate clinical documentation and its impact on patient care and safety. ClinIntell stood out as a disruptive innovation, with its “ahead of its time” algorithms and robust data analytics equipped to address the very challenges I knew the industry would eventually encounter around clinical documentation. The decision to join ClinIntell was driven by a desire to be at the forefront of transforming clinical documentation into a more efficient, precise, and quality-focused practice with physician stewardship. It was the opportunity to demonstrate that changing physician documentation practices to align with organizational goals is not an insurmountable and avoidable task. And ClinIntell’s severity reporting metrics and actionable data is the catalyst to achieving that goal in a way that no other solution or approach can.

What makes you excited to do your work every day?

Every day, there's an opportunity to bridge the gap between the clinician’s diagnostic acumen and the provider’s capacity to capture it via accurate documentation. The disparity has been perceived by the industry as an insurmountable task, but it’s not. I’ve worked with many clinical leaders and helped them leverage data in the form of ClinIntell’s advanced analytics to change their physicians’ behavior in a lean and sustainable way. When you're able to give physicians several clinical conditions to focus on based on the needs of their unique patient populations, they will engage with you. I’ve seen it happen time and time again. That’s why I’m so passionate about finding innovative ways to use data to steer the industry toward a significant positive paradigm shift in how high-quality clinical documentation is both perceived and executed.

How is Severity Reporting different than CDI?

CDI as an initiative, I think most would agree, is traditionally wrought with poor engagement amongst providers. My belief is that this stems from the approach or lack thereof that is centered around the query process alone. Severity Reporting, as a concept and an initiative resonates more with physicians. It's about clarity on their patients' conditions, which they have assessed and have a high index of suspicion for based on their evaluation and treatment modalities. We're shifting from a CDI model that can feel like it's second-guessing physicians and their clinical judgment to one that supports, collaborates, and partners with them. This approach advocates for a collective effort towards enhancing severity reporting, which is a shared organizational goal rather than a solitary initiative made up of the traditional CDI resources. With Severity Reporting, we're engaging physicians as active contributors and owners, in the documentation process, thereby fostering a more cohesive and accurate representation of patient's health and severity.

Can you share your greatest challenge and proudest achievement in this field?

The biggest challenge has been shifting the mindset of an industry that often clings to the comfort of traditional methods and is hesitant to fully engage with physicians in this transformation, mostly because of the lack of true provider-level performance metrics and actionable data. The true reward? Seeing our work truly change things, with metrics to support the sustainable change, and achieving results without over-relying on consultants or increasing the burden of documentation specialists. By delivering unparalleled results, we've turned skepticism into belief. The credit truly goes to the clinical leaders and administrators that we work with. They have embraced data-driven decisions in this space and are committed to the hands-on work necessary for real change.

Lastly, what would be your approach to encouraging physicians to engage more actively with CDI?

CDI has a reputation for being a bit of a thorn in the physician’s side, but it's not about questioning their medical decisions—it's a bridge, not a barrier. I understand that the 'black box' of clinical documentation can be a headache, but it's part of the gig. Poor documentation now hits harder than ever with penalties and quality accountability measures. So, it's not about pestering physicians with queries alone; it's about safeguarding their practice. Physicians can't avoid CDI, but they can get specific high-value conditions right the first time. It's about working smarter, not harder.

ClinIntell

Redefining Severity Reporting

ClinIntell is the only CDI data analytics firm in the industry that is able to assess documentation quality at the health system, hospital, specialty and provider levels over time. ClinIntell’s clinical condition analytics assists its clients in identifying gaps in the documentation of high severity diagnoses specific to their patient mix, ensuring the breadth and depth of severity reporting beyond Stage 1. Accountability and an ownership mentality is promoted by the ability to share peer-to-peer documentation performance comparisons and physician-specific areas of improvement.

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