MetaJumpStartYourCDIProcess

8/8/2019 MetaJumpStartYourCDIProcess

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Jump Start Your Clinical Documentation

Improvement Program with Metas eCDIApplication

Meta Health Technology IncTheLeader inHIMSolutions

Meta Health Technology Inc l 330 Seventh Avenue l New York, New York 10001

Tel: 800.334.6840 l Fax: 212.643.2913 l Web: www.metahealth.com

2010, Meta Health Technology Inc


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Jump Start Your Clinical DocumentationImprovement Program with Metas eCDI

ApplicationThe successful 2007 release of Metas Electronic Physician Query application generatedextensive interest from clinical documentation improvement (CDI) professionals across thecountry. Numerous facilities have initiated CDI programs in response to regulatory changesthat have occurred over the past few years, such as Medicare Severity-DRGs, Present onAdmission (POA) requirements and quality reporting. The objective of these programs is toobtain more specific and complete documentation that will better reflect the patients actualseverity of illness and resource consumption. However, many facilities lack the necessarytools to support a comprehensive CDI program, and therefore they find it difficult toachieve their program objectives.

Without a doubt, the CDI process presents the facility with a unique set of challenges. To beeffective, it requires a seamless process for assigning case reviews, efficient and reliablecommunication between the CDI specialist and the attending physician for query processing,appropriate and ongoing education of the physician staff, and access to tools specificallydesigned to manage and monitor the entire CDI process.

This article begins with a look at the challenges faced by many healthcare facilities with theirCDI initiatives. It concludes with a discussion of how the eCDI application from Meta HealthTechnology enables facilities to more effectively manage these critical programs.

The CDIProcess Today

For many facilities today, the CDI process is as follows.

l The clinical documentation improvement specialist (CDIS)identifies his/her review caseload for the day based on specificpatient criteria, such as assigned nursing unit, financial class orservice area.

l The CDIS reviews the concurrent medical record, typically within24 to 48 hours of patient admission to the hospital, and documentsthe review information on a hardcopy worksheet.

l The CDIS examines the record to determine whether the docu-mentation requires additional clarification or specificity from thephysician.

l If the documentation in the record includes ambiguous, unclear

or contradictory information, the CDIS initiates a written orverbal query to the physician to obtain additional documentationand/or clarification.

l The CDIS awaits the response from the physician. The querymay go unanswered if the physician is unavailable or simply doesnot respond.

This page contains Meta Health Technology proprietary information and is not to be duplicated or disclosed to unauthorized persons.

CDI & EPQ 4feb10 Meta Health Technology 800.334.6840 2


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CDI ProcessChallenges

For many facilities, one major challenge is the cumbersome, manualprocesses for identifying cases for daily reviews. CDI specialistsoften spend valuable time sorting through hardcopy census reports,manually highlighting appropriate cases based on specific patientcriteria.

Once case reviews are underway, the physician query process canpresent some of the most daunting challenges in the CDI program.Despite the good intentions of the various stakeholdersand theacknowledged impact on documentation quality and hospital reim-bursement resulting from unanswered queriesthere are numerousreasons why so many hospitals experience problems with physicianqueries.

l Lack of time and resources required to create non-leading,succinct queries that will elicit necessary responses from

physicians. Facilities may not have established language for

queries, so CDI staff are required to create a query from scratcheach time. Other facilities have hardcopy query template formsthat are not readily available to the CDIS, creating an inefficientquery generation process.

l Inaccessibility of physicians. CDI staff, HIM staff, and physiciansmay all be on different time schedules, making it difficult to locatethe physician for questions regarding documentation. Physiciansalso may not have the ability to answer queries remotely orelectronically.

l Excessive time required for ongoing follow-up with physiciansto ensure that query responses are received. Verbal query

discussions often require additional follow-up to obtain thenecessary documentation in the medical record, producing aninefficient back and forth communication process.

l Inability to reconcile concurrent queries initiated by CDISupon patient discharge. Queries that were created during thepatient stay that go unanswered often are dropped post dischargebecause HIM staff do not have the required information to followup or close the query.

Additional challenges for the CDI program include

l Lack of system integration. DRG identification often has to bedone manually, and CDI staff will not have the ability to comparevarious coding/DRG scenarios.

l Lack of appropriate management tools needed for tracking,monitoring and reporting the CDI process. Managementreports are difficult to compile on a timely basis, as informationmust often be collected manually and reformatted into legiblereports.




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Metas eCDI Solution

With an increasing number of healthcare facilities adopting Clinical DocumentationImprovement programs, Meta Health Technology developed the eCDI application toprovide facilities with a comprehensive web-based product to address all phases of the CDI

workflow process.

StreamlinesWorkflow

Metas eCDI application includes workflow automation capabilitythat provides an automated prioritized case review list for the ClinicalDocumentation Improvement Specialist. The workflow feature alsoenables physicians to be notified automatically when new queries aresent for their review. In addition, the application sends automaticreminders to physicians regarding outstanding queries based on afacility-defined timeframe.

When the physician responds to a query, the software automaticallyprovides a status update for the CDIS, thus eliminating the need to

continuously search the medical record for a query response. Oncethe query is generated, the softwares tracking capability also allowsthe CDIS and HIM staff to review its current status at any time.Furthermore, if the physician created an electronic document withthe response, the electronic document can be routed to the facilitysEMR or imaging system.

StreamlinesQueryCommunication

Metas eCDI software tackles the problems inherent in the queryprocess by facilitating communication between the CDIS and thephysician. The application allows the CDIS to easily generate aquery and attach a scanned or electronic document as a reference.

The comprehensive query is then readily accessible to the physicianfrom any remote location via a HIPAA-compliant link. In responseto a query, the physician can create and attach a facility-specificelectronic document (e.g., progress note) that is automaticallye-signed, and date and time stamped.

The query can also be forwarded to another recipient. Forwardingthe query further streamlines the communication process, as it allowsthe original recipient of the query to send the query on to anotherindividual for input or follow-up without having to manually deliverthe document. In addition, any concurrent queries initiated by theCDIS will be available to the coder following patient discharge,

eliminating both the need for the coder to review a hardcopy queryworksheet and the possibility of redundant queries.

SimplifiesQuery Creation

Whether the clinical documentation improvement initiative is managedby HIM, Case Management or another department, the facilityundoubtedly spends many hours training the responsible staff on theprocess for creating successful, compliant queries. With eCDI, userscan build their own query templates, or take advantage of an




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optional DRG-specific query library containing templates, includingMedicare MS-DRGs, APR DRGs, and New York State APR andAP-DRGs. These query templates are Medicare-compliant and thuseliminate the need for the CDI or HIM staff to spend time discerningwhether or not the queries are non-leading.

In addition to electronic queries, the CDIS can document the outcomeof the verbal query exchange with the physician directly into the eCDIapplication. Capturing this valuable information in real time makes itavailable later for inclusion in comprehensive query activity reports.

Helps Focus theCDI Program

The eCDI application provides real-time reports to help a facilitydetermine which clinical service areas require the greatest documen-tation improvement efforts. Facilities can report on physician queryactivity and response rates, providing necessary information forenforcing physician accountability. In addition, the software pro-vides reports that note the reason for the query, allowing the facilityto identify clinical documentation issues requiring further physicianeducation. It also provides CDIS-specific productivity reports.Timely access to this information allows Administration to avoid orreduce the expense of retaining outside consultants to conductextensive analysis.

Summary

Implementing a clinical documentation improvement program is an effective way to ensurethat documentation in the medical record supports the patients true clinical experience.Metas eCDI application provides a workflow-driven process that streamlines communication,

enables better query tracking and accountability, and eliminates the many obstacles inherentin the traditional CDI process. The software helps ensure that the CDI initiative producesoptimal results for the institution, including better patient care, compliance with regulatoryrequirements and appropriate reimbursement.

If youd like to discuss your facility'sCDI program, or if you'd like moreinformation about Meta's products,please call us at 800.334.6840.



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