Enhancing Your Clinical Documentation Improvement Program with Meta’s Electronic Physician Query
Posted: Tuesday, January 26, 2010
by Barbara Hinkle-Azzara
Meta Health Technology
The Clinical Documentation Improvement Program
In response to recent regulatory changes-particularly those impacting the coding process, such as Medicare Severity-DRGs and Present on Admission (POA) requirements-many hospitals have found it imperative to initiate a clinical documentation improvement (CDI) program. The principal intent of the CDI program is to obtain more specific and complete documentation that will better reflect the patient's actual severity of illness and resource consumption. Ultimately, improved documentation results in better patient care, demonstrated compliance with regulatory requirements, and in some cases, increased reimbursement.
proper and ongoing education of the physician staff, and access to tools specifically designed to manage and monitor the query process itself.
To help facilities contend with the many CDI challenges, Meta Health Technology has developed the Electronic Physician Query (ePQ) application.
The CDI Process Today
For many facilities today, the CDI process is as follows:
T he clinical documentation improvement specialist (CDIS) reviews the concurrent medical record, typically within 24 to 48 hours of patient admission to the hospital.
The CDIS examines the record to determine if the documentation requires additional clarification or specificity from the physician.
If the documentation in the record includes ambiguous, unclear or contradictory information, the CDIS initiates a written or verbal query to the physician to obtain additional documentation and/or clarification.
The CDIS awaits the response from the physician. The query may go unanswered if the physician is unavailable or simply does not respond.
For the CDI Specialist & /or HIM Staff
Lack of time and resources required to create non-leading, succinct queries that will elicit query responses from physician
Lack of access to physician to obtain query responses
E xcessive time required for ongoing follow-up with physician to ensure that query response is received
Inefficient process for communication between staff and physician
Lack of appropriate tools needed for tracking, monitoring and reporting on query process
For the Physician
Inaccessibility of CDI and HIM staff
Inability to answer queries remotely or electronically
Time-consuming process for recording additional documentation in hardcopy medical record
Meta 's ePQ Eliminates the Challenges and Enhances the Traditional CDI Program
Streamlines Communication Process
The ePQ product facilitates communication between the CDIS and the physician by allowing the CDIS to easily generate a query and attach a scanned or electronic document as a reference. The comprehensive query is then readily accessible to the physician from any remote location via a HIPAA-compliant link. In response to a query, the physician can create and attach a facility-specific electronic document (e.g., progress note) that is automatically e-signed, and date and time stamped. This document can later be printed and placed in the hardcopy record, or it can be electronically linked to the facility's electronic medical record.
The query can be also be forwarded to another recipient. Forwarding the query further streamlines the communication process, as it allows the original recipient of the query to send the query on to another individual for input or follow-up without having to manually deliver the document.
In addition, any concurrent queries initiated by the CDIS will be available to the coder following patient discharge, eliminating both the need for the coder to review a hardcopy query worksheet and the possibility of redundant queries.
Streamlines Workflow
The ePQ application has workflow automation capability that enables physicians to be notified automatically when new queries are sent for their review. In addition, the application sends automatic reminders to physicians regarding outstanding queries based on a facility-defined timeframe.
When the physician responds to a query, ePQ's workflow capability automatically provides status updates for the CDI specialist, thus eliminating the need to continuously search the medical record for a query response. Once the query is generated, ePQ's tracking capability also allows the CDIS and HIM staff to review its current status at any time. Furthermore, if the physician created an electronic document with the response, the electronic document can be routed to the facility's EMR or imaging system.
Helps You Analyze Your CDI Program Needs
The electronic physician query application provides real-time reports to help a facility determine which clinical service areas require the greatest documentation improvement efforts. Facilities can report on physician query activity and response rates, providing necessary information for enforcing physician accountability. Additionally, ePQ provides reports that note the reason for the query, allowing the facility to identify clinical documentation issues requiring further physician education.
Timely access to this information allows Administration to avoid or reduce the expense of retaining outside consultants to conduct extensive analysis.
Streamlines Query Creation
Whether the clinical documentation improvement initiative is managed by HIM, Case Management or another department, the facility undoubtedly spends many hours training the responsible staff on the process for creating successful, compliant queries. With the ePQ application, Meta offers an optional DRG-specific query library containing query templates, including: Medicare MS-DRGs, APR DRGs, and New York State APDRGs. These query templates are Medicare-compliant, thus eliminating the need for the CDI or HIM staff to spend time discerning whether or not the queries are non-leading.
Summary
Implementing a clinical documentation improvement program can provide an effective method for a facility to ensure that documentation in the medical record supports the patient's true clinical experience. Meta 's Electronic Physician Query application helps ensure that the CDI initiative produces optimal results for the institution, including better patient care, compliance with regulatory requirements and appropriate reimbursement.
The ePQ application provides a workflow-driven process that streamlines communication and eliminates the obstacles created with a traditional clinical documentation improvement process. Meta 's Electronic Physician Query will advance your documentation improvement efforts and simultaneously accomplish better physician query tracking and accountability, while providing a wealth of management reports.
For more information or a demo of Meta Health Technology products, please call Meta at 800-334-6840 or visits http://www.metahealth.com
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