I have traveled extensively since the beginning of the year, visiting prestigious organizations on both coasts and many places in between, and a recurring theme I’ve encountered involves how to remediate electronic clinical content in anticipation of the transition to ICD-10.
Between upgrades related to Stage 2 of meaningful use and ICD-10, and integration challenges associated with niche computer-assisted coding (CAC) and clinical data improvement (CDI) applications, there often is very little time or resources left over to address this vexing challenge.
Keeping clinical content refreshed is not accomplished in a vacuum, and it requires careful oversight and direction. Below I have outlined a comprehensive approach to ensure that this critical matter doesn’t fall to the bottom of your priority list:
1. Identify an organizational and committee home for clinical content updates.
I recommend that this task be charged to a currently well-functioning committee that already has medical staff representation. If no such committee exists, identify a committee that perhaps was formed during your EHR implementation, a group that has been focused on clinical documentation and can continue to tackle the job of updating and maintaining clinical documentation and templates. This group should report to a steering committee that oversees the clinical EHR system, and ultimately to your medical staff executive committee as well. If you had or have a functional medical records committee that historically has overseen this function in the world of paper, logically it could handle this important oversight and maintenance function in the digital age. Again, composition is critical, as you will want to include health information management (HIM) leadership, clinical leadership, EHR clinical information leaders, ICD-10 subject matter experts, transitional leadership and medical staff leadership. This committee also can take charge of the problem list and ensure that the specialty-specific preference lists are up to date.
2. Develop a clear and compelling charter for the committee, and publicize its charge.
Determine the key priorities for this group and develop a project plan. Make sure that you synchronize your schedule with any system updates or upgrades in order to enable the group to make recommendations, utilize new functionality and ensure that current templates are not impacted adversely in the upgrade process.
3. Utilize existing information to identify where you might need to update or create a template to facilitate the improvement of physician documentation.
If your organization performed a gap analysis to identify areas that require clinical documentation remediation, utilize this information to update all operative and invasive procedural templates for which laterality and approach must be delineated under ICD-10 PCS. Also, incorporate this additional specificity required in your specialty- or condition-specific templates. In some instances, the specificity requirements can be met with the creation of “pick lists” or additional data fields to assist providers in successfully documenting to the level of granularity required by ICD-10.
4. Develop a specialty-specific strategy, and engage the specialists in the creation and update process.
If a similar approach was used to develop clinical or critical pathways, or if you already have a functional CDI effort in place, leverage this activity to jump-start similar efforts in order to avoid reinventing the wheel. Again, involve the CDI and ICD-10 SMEs in this activity, and leave the heavy lifting to the clinical information specialists, clinical applications team and HIM to ensure the implementation of the proper and compliant design elements.
5. Educate and communicate about important updates and/or the creation of new templates and content.
This is an essential element in ensuring acceptance and proper use of the template. The achievement of broader educational goals also can be met during the rollout process using this educational front-end component. At this time, specialty-specific or condition-specific templates still can be tweaked based on feedback, which will build engagement – especially if specialists feel they have a voice in the process. These sessions should be specialty-specific or aggregated by condition to ensure a proper audience, and the “why behind the what” needs to be articulated clearly in each. Incorporate the key points, in particular that improving the integrity of clinical documentation is larger than the transition to ICD-10 and the establishment of a CDI initiative – it is about improving communication and patient care.
The next steps after the creation and rollout of your new and improved templates will involve developing a baseline by physician and within each specialty. This must reflect current clinical documentation performance and ensure the identification of where physicians presently are falling short in capturing data necessary for ICD-10.
The associated compliance and financial risk also can be gauged as part of this comparative analysis. Key performance indicators (KPIs) can be developed to measure and improve these metrics as well, especially as it pertains to your dual-coding process and the pending transition to ICD-10.
The above steps should lessen burdens and enable organizations to focus on the critical documentation elements that need to be addressed prior to this transition. Collaboration is the key, and involvement of the right mix of subject matter, clinical knowledge and provider expertise is essential in ensuring that you and your organization’s clinical documentation are refreshed and relevant.
About the Author
Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.
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