CDI Week 2018 Q&A: CDI and technology

As part of the eighth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Caryn Nowak, RHIA, CDIP, a clinical documentation specialist at Rady Children’s Hospital in San Diego and a member of the 2018 CDI Week Committee, answered these questions on CDI and technology. Contact her at cnowak@rchsd.org.

ACDIS: According to the 2018 CDI Week Industry Survey, 73% of respondents now use a completely electronic health record (EHR). Last year, that group included 47.56% of the respondents. How do you see the rapid adoption of EHRs changing the way CDI professionals conduct their jobs?
Nowak: The adoption of the EHRs has changed the workflow in several different ways. The portability of EHRs allow clinicians and CDI professionals greater flexibility in reviewing and completing documentation. EHRs allow clinicians to review and respond to an electronic query without the paper chart in hand. With the implementation of EHRs, CDI professionals have seen an increase in documentation, so while there may be more flexibility, there may be a decrease in productivity. Computer-assisted coding (CAC) software applications have been one way the industry has responded to help the CDI specialist become more productive.

ACDIS: Where does your facility/organization stand when it comes to EHR implementation?  
Nowak: Rady Children’s Hospital – San Diego (RCHSD) is fully live with 95% of all EHR applications.

ACDIS: Were there any real sticking points with the transition to a fully electronic system?
Nowak: There was a time when CDI professionals could “follow the paper chart” in order to have one-on-one conversations with the clinician. It may be more difficult to track down the physician now because they are no longer sitting in the unit completing the chart.

ACDIS: According to the Industry Survey, 53% of respondents use CAC or natural language processing (NLP). Does your organization use CAC or NLP to assist with record reviews? If yes, how has it affected your CDI workflow and productivity?
Nowak: RCHSD leverages a CAC software application for both coding and CDI workflows. CAC has brought inpatient coding productivity to near what it was prior to the 2015 implementation of ICD-10. For CDI workflows, CAC applications have allowed for better reporting, query identification, and integration into the EHR.

ACDIS: Do you work directly with your IT department?
Nowak: At RCHSD, the CDI team reports to the HIM director, who reports directly to the chief information officer, so there is a direct relationship with IT. CDI team members are able to work directly with EHR analysts to troubleshoot issues with physicians and their standardized EHR templates. They also work with the team of HIM analysts supporting CAC. 

ACDIS: Does your IT representative regularly sit in on meetings with the CDI team, or does the administration regularly meet with the IT representative?  
Nowak: CDI team members sit on various multidisciplinary workgroups at RCHSD, including but not limited to clinical decision support, health information medical advisory council, and note quality.

ACDIS: Does your IT representative from your facility regularly meet with representatives from your CDI and EHR vendors? 
Nowak: HIM informaticists meet regularly with technical and analyst groups for both RCHSD EHR and CAC vendors.

ACDIS: Do you take provider feedback into account when changing, updating, or enhancing functionality in the EHR or CDI software?
Nowak: Yes. At RCHSD, we work with our chief medical informatics officer and her team to suggest physician documentation workflow enhancements—in particular, to identify template design that will best impact the CAC engine’s ability to digest notes and auto-suggest codes.

ACDIS: Do you have staff who now work remotely as a result of the electronic system? If so, are they 100% remote, or do they work part-time on-site and part-time at home?
Nowak: Yes, RCHSD CDI team members work remotely, as well as on the hospital units.

ACDIS: How has remote staffing affected productivity and physician engagement?
Nowak: Allowing staff to spend a few days a week remotely gives them quiet and undisturbed time outside of patient care areas and helps RCHSD continue to be an employer of excellence. Giving team members the opportunity to work remotely has increased their job satisfaction, which in turn provides a higher level of employee engagement. With highly engaged team members, this ends up translating to higher physician engagement.

ACDIS: How do you handle team education with remote team members?
Nowak: Team education is both handled in person and via webinar.  

ACDIS: What about physician education?
Nowak: Physician education is handled in person and via tip sheets and specialty scorecards. CDI physician champions may also attend CDI webinars with the CDI team.

ACDIS: Is copy/paste an issue at your organization? If so, how is CDI working to combat it?
Nowak: RCHSD has a policy for documentation in the patient’s medical record which also includes reference to appropriate use of copy and paste. CDI team members and coding team members will also look for issues that may be the result of copy and paste. Additionally, as EHR software has developed, there are now internal tools/reports to help identify potential issues with copy/paste, thus requiring less manual user identification.

ACDIS: How have you leveraged technology to improve CDI efforts (e.g., have you built query templates in the EHR or prompts for the physicians using dropdowns, etc.)?
Nowak: CDI team members review real-time reports daily for data mining to find potential notes requiring further specificity. In some cases, dropdowns have been embedded in physician templates to identify areas requiring further specificity at the front end.

Standardized physician query templates have also been created in the EHR.

ACDIS: Can you provide an example or a specific outcome?
Nowak: CDI team members review a daily report for hospital problem list creation and, when necessary, send a physician query as a reminder to complete the hospital problem list.

Certain physician query templates were updated to highlight when diagnosis specificity is necessary.

ACDIS: According to the Industry Survey results, 13% of respondents are planning to move to an electronic record by the end of the year or sooner. What would you recommend to them to ensure a smooth transition?
Nowak: Ensuring that CDI is part of the design team/committee is important to ensure a smooth transition. It is important to participate in the design and be able to provide feedback from the end user perspective and from the perspective of looking at reports and analyzing the data.