Book excerpt: CDI specialists’ role with the EHR
to Provider Queries
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
As medical information moves from paper-based to electronic, CDI professionals as well as providers, hospital clinical and administrative leaders, coders, and other record analysts must consider the following questions:
- Who owns or has responsibility for the content and structure of the EHR?
- How is the EHR organized to locate the information necessary for the reviewer?
- Are all necessary components included in the record and updated when clinically appropriate?
- Does the electronic record still “tell the story” of the patient’s encounter?
CDI and HIM teams serve as important voices during a facility’s transition to an electronic record. As providers begin to learn how to use the EHR, they should also understand how the data will be transmitted to and used by other departments. CDI professionals can target queries and education to help them understand what key information and data points are needed for an accurate clinical picture on the coding side. Additionally, CDI can facilitate dialogue with the IT department and advocate on behalf of providers who continue to struggle with their electronic system. This input can lead to improvements in the EHR structure and educational opportunities for all parties.
CDI should understand the processes required for a provider to enter information into an EHR. CDI can then incorporate the provider’s perspective and construct query templates based on their needs and existing workflows.
Understanding how a provider’s behavior influences the quality of the data is equally important, especially with regard to copy/paste functionality. Facilities should have policies in place to regulate and monitor copy/paste, as this functionality could affect both patient care and the quality of the medical record.
EHR functionality has helped eliminate or reduce the use of symbols to represent clinical changes, such as h, i, or abbreviations such as R/O. In turn, though, it has also led to an uptick in the use of acronyms to describe diagnoses, likely related to the common provider complaint of “too many keystrokes.” For instance, acronyms like “ADHF” and “HCAP” may be a viable shortcut for providers, but a query will still be needed when a condition is considered conflicting, incomplete, or ambiguous.
CDI participation can strengthen and facilitate the success and quality of an EHR. Gone are the days of seeking provider buy-in to an EHR. It is now a necessary component of healthcare delivery, and CDI can support providers in using it and increase its ease of use.
Editor’s note: This article is an excerpt from The Essential CDI Guide to Provider Queries.