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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? [more]

Guest Post: Natural language processing and clinical documentation, part 2

CDI and technology

New technology heavily affects CDI and coding.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Effect on coders

Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP) technology, coding’s job becomes much easier. From the physicians/providers to the CDI specialists, NLP helps ensure documentation is robust, with conditions that have been queried when necessary and fully specified—producing a fully documented encounter by the time the chart crosses the coder’s desk.

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Guest Post: Natural language processing and clinical documentation, part 1

CDI and technology

Many clinicians now use dictation software and EHRs.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Long before ICD-10-CM/PCS became a focus, working as a clinical documentation improvement (CDI) manager to improve physician progress and/or operative notes was a challenge—doctors either got it or they didn’t. But as the transition from paper charts to an electronic health record (EHR) began, providers started to understand how to better document their visits, since they had to choose from drop-down menus and multiple options to complete their notes. Then, as ICD-10 approached, a new awareness of medical necessity denials and revenue impact took shape. Providers began looking for ways to document better in less time.

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Tip: Advance CDI’s cause through technology

CDI and technology

Technology changes the way CDI operates every day.

Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.

Then, electronic health records (EHR) came on the scene, changing the CDI process for nearly everyone.

“Simply put, the advent of EHRs and e-queries changed how CDI specialists work—and the days of misplaced paper queries and incoherent penmanship are all but gone,” according to a special report out from ACDIS and HealthLeaders Media, in partnership with Optum360, “Leveraging technology to advance CDI efforts.”

Like all changes, EHR comes with rewards and challenges. CDI programs gain the flexibility and supportive data to meet the needs of the healthcare systems they serve. All while increasing productivity.

“With any new system, issues are going to have to be addressed,” Kathy McDiarmid, RN, CDI specialist at Beverly Hospital, a member of the Lahey Health System in Massachusetts, told the CDI Journal in December.

“There will be little things that physicians forget,” she says. Yet armed with intimate knowledge of the programs chosen, CDI staff can help physicians navigate the EHR and provide real-time assistance once the programs are in use, says Colleen Stukenberg, RN, MSN, CMSRN, CCDS, director of resource management at FHN in Freeport, Illinois, in a 2016 CDI Week Q&A for ACDIS.

In order to fully leverage the new technology, according to the report, CDI specialists need to understand the technology first. This knowledge gives them another platform from which to reach out to physicians. The CDI team can be a resource and help ease the transition to a new system for the physician.

To learn more about leveraging your EHR system to improve physician engagement and productivity, read the entire report by clicking here.