September 22, 2017 | | Comments 0
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CDI Week Q&A: CDI and Technology

Wall, James

James Wall, RN-TN, BSN, MBA

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. James Wall, RN-TN, BSN, MBA, the senior director of clinical documentation improvement at LifePoint Health in Brentwood, Tennessee, and a member of the 2017 CDI Week Committee, answered these questions on CDI and technology. Contact him at james.wall@lpnt.net

Q: How long have you had electronic health records?

A: I am a systems Senior Director of CDI. Since LifePoint has acquired many hospitals, we have assumed a variety of different EHR systems. While there is not a standard EHR, LifePoint uses three main Health Information Systems. Many of our hospitals are totally electronic while others are a hybrid of EHR and paper.

Q: Have there been any real sticking points with the transition to full electronic systems?

A: When I worked at another health system, I was very involved in the transition from a paper chart to an electronic chart. As with any change, some practioners were resistant, others embraced the new system readily. Three months after implementation there was no resistance. It was as if we had always been on the EHR. I see no downside to a fully electronic system as long as it works well and has excellent IT support and super users.

Q: What next steps are needed to make sure everything continues to run smoothly?

A: There are really three things you need to ensure a smooth process:

  1. Senior leadership commitment to the process change
  2. A competent support team that is available 24/7
  3. Provider champions to support the transition

Q: Do you have an electronic query system separate from the EHR?

A: Yes, LifePoint uses ChartWise. It’s our standard CDI software. It’s an excellent software that is user friendly and intuitive to use. LifePoint has adopted the ChartWise query library as our corporate queries for both CDI and coders as well. ChartWise has won the KLAS Awards for customer service for the last three years. In my opinion, it also has the best metric reporting system in the market.

Q: Do you have staff who work remotely now that you’re electronic? If so how has that affected productivity and physician engagement with the CDI team? If so, how do you handle team education?

A: We are testing this in two different markets. At the sites that are doing remote CDI, there is always a CDI specialist on-site to answer any questions or concerns posed by the providers.

For CDI to be successful, it needs a human face. It can be the CDI supervisor or even the HIM director, but someone needs to be the human go between. I believe CDI needs to be physically engaged with the provider, not perceived as a remote faceless bureaucrat.

Q: Were there challenges related to the CDI conducting reviews in the EHR or challenges facing physicians following your EHR implementation?

A: Once the CDI specialist has learned to navigate the EHR there were no real issues finding clinical indicators, etc. We did have some challenges when determining the best way to present the query to the physician. The query needs to integrate with the provider’s workflow; not vice versa. The simplest approach is to ask the physician what is the best way for the query to be presented.

Q: Are note bloat and copy/paste a problem at your facility, and if so, how are you working to combat it?

A: In some facilities, but overall education has limited the practice in our experience.

Q: How have you leveraged technology to improve CDI efforts?

A: Since LifePoint has several types of EHR, the system has adopted Chartmaxx. This is essentially a patient folder for each hospital encounter. It not only helped CDI, but other applications used by the local hospitals.

Q: What advice do you have for people transitioning to EHRs?

A: Vet several vendors and don’t be swayed by their sales pitch. Some EHRs are very expensive for a system to adopt. Speak to current users and visit their facilities to see the EHR live. Ask questions, then ask some more questions. It is a long term project and requires several good project managers and real commitment.

 

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Filed Under: ACDISCDI ProfessionCDI Recognition WeekClinical Documentation ImprovementEHRGrowing your programManagement

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Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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