Jump Start Your Clinical Documentation Improvement Program with Meta's eCDI application...Part 2                               Go to Part 1

With an increasing number of healthcare facilities adopting Clinical Documentation Improvement (CDI) programs, Meta Health Technology developed the eCDI application to provide facilities with a comprehensive web based product to address all phases of the CDI workflow process.

Streamlines Workflow

Meta's eCDI application includes workflow automation capability that provides an automated prioritized case review list for the Clinical Documentation Improvement Specialist (CDIS.) The workflow feature also 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, the software automatically provides a status update for the CDIS, thus eliminating the need to continuously search the medical record for a query response. Once the query is generated, the software's tracking capability also allows the CDI Specialist and HIM staff to review the query’s 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.

Streamlines Query Communication

Meta's eCDI software tackles the problems inherent in the query process by facilitating communication between the CDIS and the physician. The application allows 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.

The query can 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.

Simplifies 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 eCDI, users can build their own query templates, or take advantage of an optional DRG-specific query library containing templates, including: Medicare MS-DRGs, APR DRGs, and New York State APR and AP-DRGs. 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.

In addition to electronic queries, the CDI Specialist can document the outcome of the verbal query exchange with the physician directly into the eCDI application. Capturing this valuable information in real time makes it available later for inclusion in comprehensive query activity reports.

Helps Focus The CDI Program

The eCDI 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. In addition, the software provides reports that note the reason for the query, allowing the facility to identify clinical documentation issues requiring further physician education. It also provides productivity reports specific to CDI specialists. Timely access to this information allows Administration to avoid or reduce the expense of retaining outside consultants to conduct extensive analysis.

Summary

Implementing a clinical documentation improvement program is an effective way to ensure that documentation in the medical record supports the patient's true clinical experience. Meta's eCDI application provides a workflow-driven process that streamlines communication, enables better query tracking and accountability, and eliminates the many obstacles inherent in the traditional CDI process. The software helps ensure that the CDI initiative produces optimal results for the institution, including better patient care, compliance with regulatory requirements and appropriate reimbursement.

If you'd like to discuss your facility's CDI program, or if you'd like more information about Meta's products, please call us at 800.334.6840.