All Entries in the "IT" Category
CDI staff play an important role in the transition to electronic health record
Don't let the transition to electronic records become speed bumps to your CDI program efforts.
As I was waiting in the security screening line in an airport recently, I overheard two women speaking together regarding the need to give up their cellphones to the x-ray machine. One commented, “I can’t give up my phone. It’s my life and I can’t imagine what would happen if I lost it or if its contents were erased.”
The conversation seemed like a classic illustration of our dependence on technology. Yet just a few years ago many of us proudly stated that we would “never become dependent” upon these devices.
I personally remember stating that I’d NEVER join the texting world and yet here I am not only texting my family, but colleagues, and clients as well. I’ve witnessed many a nurse “text” a message to a physician. These same physicians are now being asked to complete orders electronically and many are beginning required to document care via an electronic medical record (EMR).
So what are the effects of EMR’s on the world of clinical documentation improvement? Well, it certainly hasn’t erased the need for clarification of documentation. It may actually create more queries than it eliminates. Legibility may have improved but identification of conditions being monitored and treated is still often lacking in clinical documentation. The way physicians assess and treat patients haven’t changed, the only thing different is how their thoughts are captured in the medical record.
Physicians who have always provided a detail-less “story” of the admission will still need to be queried to identify the conditions they are caring for during the admission. Drop downs and templates designed to make documenting easier for physicians, often create confusion and misrepresentation of patient conditions so this too will result in the need for clarification.
CDI specialists continue to be a primary resource for physicians, providing education regarding appropriate and compliant documentation. This is particularly true when supporting documentation within an EMR.
Therefore, CDI specialists need to have a thorough working knowledge of the electronic program being used for physician documentation so they can provide support to physicians. Supporting appropriate use of possible drop down choices or checklists ensures that accurate documentation of the patients’ severity of illness is captured in the record. Often CDI specialists participate in the nursing portion of EMR training but it is equally important for them to understand the provider applications so they can help train and guide physicians through use of the program.
Electronic queries pose their own unique issues as well. In 2009, Barbara Hinkle-Azzara, RHIA, VP of Operations for Meta Health, in New York City, identified 10 tips that support use of electronic queries to streamline the query process and provision of a direct link to the EMR. She points out some key reasons that support the use of electronic queries but it is important to ensure that the proper education is made available to providers so they use the system correctly.
Monitoring physician response rates before and after transition to an electronic system will assist in identification of possible process issues including the possibility that physicians are not addressing queries because they don’t know where to find them in the EMR.
Clearly due to the need to move to the EMR, electronic queries will become the “new” method of clarifying documentation issues with physicians. CDI specialists should not fear the move to EMR’s as even the most sophisticated EMR is not likely to eliminate the need for the CDI specialist role in serving as a “documentation resource” to healthcare providers.
However, it is important that CDI specialists are prepared to serve as a resource to physicians and are adequately educated regarding the proper use of the EMR program and the electronic query process.
E-query case study: Memorial Hermann streamlines systems
By Anna Wheeler, MPH, RHIA, CCS
Still afraid of electronic query systems? Read what Memorial Hermann has to say about them.
Prior to implementing an electronic query application from Meta Health Technology in 2010, the query process at Memorial Hermann was completely manual and extremely time-consuming. To submit a post-discharge query, the coder created a Word document and sent the query to the inpatient coding coordinator for review.
The coordinator then determined if the query was required and faxed it to the physician’s office along with a blank progress note for physician response. If the physician responded, the coordinator sent the response to the HIM department secretary. The secretary forwarded it to the scanning team at the corporate HIM department to be scanned into the record.
Additionally, the coding supervisor sent an email to the coder indicating that a response was available and to complete the coding of the record. If there was no response after 30 days, the coder completed coding the chart without the response.
Clearly, our query process was ripe for automation. Internally, Memorial Hermann had set specific objectives for improving clinical documentation and eliminating manual processes wherever possible throughout the facility. Further, we knew that unanswered physician queries were affecting our reimbursement, yet we had no way to track and report on response rates and the associated financial impact.
The right fit
We had the opportunity to view an early demonstration of Meta’s ePhysicianQuery software. Since Memorial Hermann utilizes a combination of concurrent and post-discharge queries, a team comprised of representatives from HIM, HIS and our CDI initiative evaluated the new software.
We concluded that the application offered the functionality we needed and would integrate seamlessly with both our document management system and the physician in-box in Care4, Memorial Hermann’s core clinical application. Equally important, the query software would integrate with the facility’s EMR, so that the documentation provided electronically by physicians would automatically become part of the legal medical record.
Easy for physicians
One of Memorial Hermann’s objectives was to automate the query process so it would be easy for physicians to respond to queries. Previously, physicians received queries by fax, and then had to locate the record, find the documentation in the record that prompted the query, and take a separate action to create an addendum. Now, queries are emailed to the physician’s in-box, already sorted by facility, along with attached documents containing the relevant patient records. Physicians are provided with a blank electronic progress note, allowing them to easily provide the necessary documentation and quickly close out the query.
To ensure that physicians would be comfortable using the software, our information systems staff provided a web-based training video available in the doctors’ lounge, as well as convenient pocket cards highlighting key functionality of the application.
Immediate Benefits in HIM
As a result of implementing the new query software, we saw a number of important benefits. The HIM Department experienced immediate improvement in streamlining workflow. Now our coders easily generate a query directly from within their abstracting workflow using the new application. They simply click a button, and the query window opens, with all the patient demographics and physician data automatically populated.
Additionally, tracking queries is effortless, as coders can immediately determine what queries are outstanding as soon as they open the application. To gain maximum benefit from the software, we have developed a set of templates for our most common queries. These queries are now standardized, so the message to physicians is consistent, and we don’t need to spend time creating queries from scratch.
From a user perspective, the new query software has been a success. We surveyed our inpatient coding staff to assess their response to the software, and the feedback was uniformly enthusiastic. With the query templates and minimal data entry, coders can work quickly and efficiently.
Reporting
Another significant benefit is that HIM now has the ability to easily produce reports on our query process, including the number of queries, query rate, response rate and query turnaround time. We can identify the physicians who are not responding, and measure the impact on reimbursement of their unanswered queries. The “Top Reasons for Query” report is particularly useful, because it enables us to look at patterns to discern educational opportunities. For example, if there is a high volume of CHF queries, we can bring that information to the Cardiology Section meeting and highlight where the physicians need to provide additional specificity in their documentation.
In addition, we have seen an improvement in the coordination and interaction between coders and
CDI Specialists. We can compare the querying patterns of the two groups, review the data together, and determine which diagnoses and treatment areas require additional focus.
Next stop: CDI
Memorial Hermann is eager to build on the results achieved using the electronic query software for inpatient coding, and is now leveraging that experience with the facility’s CDI program.
“We view this experience as a single, major documentation improvement project. Using the query software has brought to light the opportunities for us to assess and re-design our processes on the front end,” says Carol Paret, Chief Community Benefits Officer and Privacy & Security Officer at Memorial Hermann. “For example, our documentation specialists are now centralized; thanks in part to the data produced by the query application, we have re-tooled their job descriptions and workflow.”
An immediate next step is to have the CDI specialists begin using a version of the software called “eCDI” that is designed specifically for such programs. “The eCDI tool will allow for the creation of a unique CDI database—separate from the coding database—that will improve data capture at the front end. It will also enhance our e-query processes, especially the query closeout process. These improvements will result in more accurate capture and reporting of front-end query data,” says Joy Coletti, MBA, RN, CDI trainer for Memorial Hermann Healthcare System.
The eCDI tool automatically assigns cases to CDI Specialists based on Memorial Hermann’s facility-specific rules. “Most of MHHS’s cases are assigned geographically, by nursing unit, but the software also enables an individual facility to assign by service line, so that, for example, cardiology cases can be directed to a CDI nurse with a strong cardiology background,” Coletti says.
“The eCDI tool will also allow the CDIS’s to utilize electronic Clinical Documentation Worksheets, instead of paper worksheets, to capture their clinical data, fully automating data capture on the front end. This will enhance daily follow up and transfer of cases to another CDIS, in the event of illness or vacation,” says Coletti.
Finally, let’s not forget ICD-10
Not a surprising finding, but according to a 2010 ACDIS survey, 81% of respondents expect to see an increase in query volume when the new ICD-10 system is live. We believe having the query software in advance will make the transition on October 1, 2013 quite a bit easier for us at Memorial Hermann.
Editor’s Note: Anna Wheeler, MPH, RHIA, CCS, is director of Coding Services at Memorial Hermann Healthcare System in Houston, Texas. Memorial Hermann Healthcare System is the largest not-for-profit healthcare system in Texas and serves the greater Houston community through 11 hospitals, a vast network of affiliated physicians and numerous specialty programs and services.
Clear, concise, precise use of language
Clear language has become a presidential priority? Where does CDI leave its mark?
“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a few years ago, and remember chuckling at the best and worst examples of effective communication.
Most CDI professionals no doubt would be surprised that an organization such as The Center for Plain Language exists. Many would also find it surprising to learn that President Barack Obama signed The Plain Writing Act of 2010 into law back in October and that the Office of Management and Budget recently drafted preliminary guidance for implementation of the new legislation. The law “requires the federal government to write all new publications, forms, and publicly distributed documents in a ‘clear, concise, well-organized’ manner that follows the best practices of plain language writing.”
The idea, of course, is that a well-informed public can better abide by, and influence promulgation of, the rules and regulations of their society. Such an ideal seems simple enough, and worthy enough, yet when applied to the profession of CDI, the complicated nature of this endeavor reveals itself.
Let me explain.
At its most elemental, the CDI specialist serves as translator between healthcare’s clinical and coding languages. Each of these languages has developed over many decades and is complete with its own rules and nuances of use.
Physicians spend in excess of 10 years of schooling learning the language of the body’s processes and the latinate words we use to describe those processes. What cardiologists are able to quickly communicate to each other may not be as easily understood if, for example, a cardiologist attempted to communicate a clinical scenario with a nephrologist. The language each type of physician uses may be precise to his or her own awareness of the conditions and according to the familiarity of how those words and phrases are used in their daily lives.
Although the language of medical coding may not have its history rooted in ancient Greek, it nevertheless dates back to the early 1800s when the first International List of Causes of Death (then called the Bertillon Classification of Causes of Death) was adopted by the International Statistical Institute at a meeting in Chicago, according to The HIM Director’s Guide to ICD-10. Since then, the International Classification of Diseases (ICD) has evolved through 10 revisions and contains not only more than 150,000 codes, but multiple details of instructions in the Official Guidelines for Coding and Reporting regarding the application of those codes.
Add to all this the complexity of transmitting the coded elements of healthcare information electronically to a variety of entities, including research agencies, government and private payers, physicians, and yes, sometimes even to the patients themselves. To do this, the American National Standards Institute (ANSI) Transaction Version 5010 and National Council for Prescription Drug Programs (NCPDP) Version DO and 3.0 needs to be implemented, which includes more than 850 structural, technical, and content changes to the current system.
Where is the simplicity of “plain language”?
Bear with me, please, as I am not quite done outlining the complexity of dialogue which currently governs our healthcare system. In several recent conversations, CDI professionals have expressed their frustration with CDI involvement in the planning for, and implementation of, electronic health records.
Depending on how precise your awareness is of this process, you may not know, for example, that an electronic health record (EHR) is not the same thing as an electronic medical record (EMR). An EHR is the global term encompassing all electronically-generated components of a computer-based patient record. It generally refers to hospital- or facility-based records, as opposed to the EMR, which is the global term encompassing all electronically-generated components of a computer-based patient record—generally refers to physician-, professional-, or clinic-based records. (Read more on these definitions in a previous blog post.)
All of this would (could? should? does?) make the indoctrinated individual’s mind recoil at the complexity of it all. And yet, this is the world CDI specialists enter every day as they attempt to translate missing or vague physician documentation into as precise a collection of words as possible to illustrate the clinical condition of the patients under their purview.
Every year, The Center for Plain Language calls for nominations for its ClearMark Award. Unfortunately, CDI as a profession would not be eligible. I am sure, however, that those in this field labor to follow the Center’s basic premise that:
- “Plain language is information that is focused on readers. When you write in plain language, you create information that works well for the people who use it, whether online or in print.
- Plain language is behavioral: Can the people who are the audience for the material quickly and easily find what they need, understand what they find, and act appropriately on that understanding?”
At its best, a well-implemented CDI program will help the physician use plain and precise language throughout the medical record so that everyone who needs to use that information—from nurses to coders, from IT to billing, and even from physicians to their patients—can understand and use that information.
Column: The myth of ‘meaningful use’
The search for 'meaningful use' in electronic health records continues.
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have been a myriad of interim steps, from models which simply scan the handwritten documents into a computer system to those which begin with an electronic template complete with check boxes and drop down menus.
Some programs use dictated and transcribed elements for physician or mid-level provider entries. Some programs take the electronic record and utilize fuzzy logic to search for key words, phrases, and abnormal lab results in an attempt to assign ICD diagnosis codes.
But what is the purpose of this transition? What is the stated goal? What is the real goal to be achieved with an EHR? There are two major reasons for the development and adoption of the EHR. One we are close to achieving, the other, in my opinion, just doesn’t exist.
The desire to ensure that an electronic model of a patient’s encounters contains all of the elements needed for somebody’s perception of a “complete” record has led to the currently marketed and sold models. To know that a patient’s problem list is present, that his or her medication list and reconciliation is there, to know that the history and physical (H&P), progress notes, discharge summary, nursing notes, and all the rest of the elements that make up a traditional patient’s chart are present is a great reason to have an electronic record. It forces people to remember to make these entries. Also important is the electronic records ability to:
- Keep the patient’s inpatient and outpatient encounters available in one compendium
- Track crossover treatments provided by different specialists
- Monitor for drug interactions
- Track scheduling and follow-up visit dates
The potential to facilitate practice guidelines and order sets based on best practice is great—if the physician knows how to set them up and use them or, in specific cases, elect not to use them for the benefit of the outlier patient. So, for these reasons, I say good for the companies who have put such an important functionality together.
But, there are still problems with implementation of the so-called complete EHR. In the January 2011 edition of the Journal of AHIMA, Genna Rollins writes about the experience of Barbara Drury, president of Pricare Consulting. According to the article, Drury experienced difficulties with the EHR recording inappropriate dates at inappropriate times. She also expressed frustration with the inability of tracking patient data when someone does not have access to the electronic record and worried about those who would then develop alternative, manual, work-arounds.
Yes, there are still process issues.
Definition of healthcare IT acronyms
After spending some time writing the recent CDI Journal article regarding electronic query systems I came to realize that information technology (IT) in the healthcare world has as many intricacies as clinical documentation does.
For example, have you ever noticed how Microsoft Word automatically changes the acronym EHR for electronic health record to HER, as in this is HER shirt. To eliminate the challenge I adopted the phrase electronic medical record (EMR) instead. These two terms, however, do not mean the same thing.
Terminology in healthcare IT can be as difficult to parse as those in clinical documentation. It's not as simple as the difference between 'toe-may-toes' versus 'to-mah-toes'.
I’m not talking about Fred Astaire and Ginger Rogers arguing over the pronunciation of tomato either (or either).
A little research later, I came across the following Medical Records Briefing article written by Darice M. Grzybowski, MA, RHIA, FAHIMA, who spoke at the 2010 ACDIS Conference in Chicago. Although CDI specialists may not find themselves worrying about this aspect of jargon and its use, misuse, and abuse I found it both interesting and somewhat helpful in developing a language awareness in regard to the electronic query debate. I thought you might find it interesting also.
What’s in a name: Healthcare IT’s addiction to acronyms
by Darice M. Grzybowski, MA, RHIA, FAHIMA
The following text comes from the National Alliance for Health Information Technology (NAHIT) Web site (www.nahit.org) posting dated October 24, 2007:
“The National Alliance for Health Information Technology is leading an important effort for the Office of the National Coordinator for Health Information Technology (ONC) to develop consensus-based definitions for key health information technology terms . . . A cacophony of competing and confusing definitions, with terms often used interchangeably, is impeding progress in health information technology. A common understanding and use of terms are essential for facilitating IT adoption and innovation and achieving a useful exchange of health information to improve patient outcomes.”
The following text comes from the Modern Healthcare Online’s Web site (www.modernhealthcare.com) posting dated October 26, 2007:
“What’s the difference between an EMR, an EHR, and a PHR? Why is an HIE not a RHIO? Does anyone really care? Well, yes, the Office of the National Coordinator for Health Information Technology at HHS cares enough to pay contractors close to a half million dollars to come up with the answers. ONCHIT awarded a contract to technology and management consultant BearingPoint, McLean, VA, to develop consensus definitions for the initial-isms and one acronym, some of which (EMR and EHR, HIE and RHIO) are often used interchangeably by the healthcare hoipolloi but are occasionally argued over vehemently by the IT cognoscenti.”
How did we get to the point that such extreme dollars and taxpayer monies are needed to pay consulting firms to sort out the alphabet soup in the acronym-addicted world of healthcare informatics? Technology differences aside, there is no doubt that communication errors occur when individuals do not use the same terminology to refer to the same type of system. And terminologies for components of the electronic health record are no isolated exception in healthcare vernacular confusion.
After all, how many different ways are there to refer to certain diagnoses? Consider hypertension, also known as HTN, or elevated blood pressure, or increased diastolic/systolic pressures, or HBP, and the list goes on. We have all learned the lessons of the dangers of abbreviation misuse in clinical documentation and have been warned by The Joint Commission (remember the organization formerly known as JCAHO?) about avoiding abbreviation use as a final diagnosis.
Sometimes a rose is a rose is a rose—such as when CHINs turned into NHINs turned into RHIOs turned into HIEs. No wonder there is mass confusion and overlapping objectives. [more]
