Guest Post: E-query case study: Memorial Hermann streamlines systems

By Anna Wheeler, MPH, RHIA, CCS

Prior to implementing an electronic query application from Meta Health Technology in 2010, the query process at Memorial Hermann was completely manual and extremely time-consuming. To submit a post-discharge query, the coder created a Word document and sent the query to the inpatient coding coordinator for review.

The coordinator then determined if the query was required and faxed it to the physician’s office along with a blank progress note for physician response. If the physician responded, the coordinator sent the response to the HIM department secretary. The secretary forwarded it to the scanning team at the corporate HIM department to be scanned into the record.

Additionally, the coding supervisor sent an email to the coder indicating that a response was available and to complete the coding of the record. If there was no response after 30 days, the coder completed coding the chart without the response.

Clearly, our query process was ripe for automation. Internally, Memorial Hermann had set specific objectives for improving clinical documentation and eliminating manual processes wherever possible throughout the facility. Further, we knew that unanswered physician queries were affecting our reimbursement, yet we had no way to track and report on response rates and the associated financial impact.

The right fit

We had the opportunity to view an early demonstration of Meta’s ePhysicianQuery software. Since Memorial Hermann utilizes a combination of concurrent and post-discharge queries, a team comprised of representatives from HIM, HIS and our CDI initiative evaluated the new software.

We concluded that the application offered the functionality we needed and would integrate seamlessly with both our document management system and the physician in-box in Care4, Memorial Hermann’s core clinical application. Equally important, the query software would integrate with the facility’s EMR, so that the documentation provided electronically by physicians would automatically become part of the legal medical record.

Easy for physicians

One of Memorial Hermann’s objectives was to automate the query process so it would be easy for physicians to respond to queries. Previously, physicians received queries by fax, and then had to locate the record, find the documentation in the record that prompted the query, and take a separate action to create an addendum. Now, queries are emailed to the physician’s in-box, already sorted by facility, along with attached documents containing the relevant patient records. Physicians are provided with a blank electronic progress note, allowing them to easily provide the necessary documentation and quickly close out the query.

To ensure that physicians would be comfortable using the software, our information systems staff provided a web-based training video available in the doctors’ lounge, as well as convenient pocket cards highlighting key functionality of the application.

Immediate Benefits in HIM

As a result of implementing the new query software, we saw a number of important benefits. The HIM Department experienced immediate improvement in streamlining workflow. Now our coders easily generate a query directly from within their abstracting workflow using the new application. They simply click a button, and the query window opens, with all the patient demographics and physician data automatically populated.

Additionally, tracking queries is effortless, as coders can immediately determine what queries are outstanding as soon as they open the application. To gain maximum benefit from the software, we have developed a set of templates for our most common queries. These queries are now standardized, so the message to physicians is consistent, and we don’t need to spend time creating queries from scratch.

From a user perspective, the new query software has been a success. We surveyed our inpatient coding staff to assess their response to the software, and the feedback was uniformly enthusiastic. With the query templates and minimal data entry, coders can work quickly and efficiently.

Reporting

Another significant benefit is that HIM now has the ability to easily produce reports on our query process, including the number of queries, query rate, response rate and query turnaround time. We can identify the physicians who are not responding, and measure the impact on reimbursement of their unanswered queries. The “Top Reasons for Query” report is particularly useful, because it enables us to look at patterns to discern educational opportunities. For example, if there is a high volume of CHF queries, we can bring that information to the Cardiology Section meeting and highlight where the physicians need to provide additional specificity in their documentation.

In addition, we have seen an improvement in the coordination and interaction between coders and

CDI Specialists. We can compare the querying patterns of the two groups, review the data together, and determine which diagnoses and treatment areas require additional focus.

Next stop: CDI

Memorial Hermann is eager to build on the results achieved using the electronic query software for inpatient coding, and is now leveraging that experience with the facility’s CDI program.

“We view this experience as a single, major documentation improvement project. Using the query software has brought to light the opportunities for us to assess and re-design our processes on the front end,” says Carol Paret, Chief Community Benefits Officer and Privacy & Security Officer at Memorial Hermann. “For example, our documentation specialists are now centralized; thanks in part to the data produced by the query application, we have re-tooled their job descriptions and workflow.”

An immediate next step is to have the CDI specialists begin using a version of the software called “eCDI” that is designed specifically for such programs. “The eCDI tool will allow for the creation of a unique CDI database—separate from the coding database—that will improve data capture at the front end. It will also enhance our e-query processes, especially the query closeout process. These improvements will result in more accurate capture and reporting of front-end query data,” says Joy Coletti, MBA, RN, CDI trainer for Memorial Hermann Healthcare System.

The eCDI tool automatically assigns cases to CDI Specialists based on Memorial Hermann’s facility-specific rules. “Most of MHHS’s cases are assigned geographically, by nursing unit, but the software also enables an individual facility to assign by service line, so that, for example, cardiology cases can be directed to a CDI nurse with a strong cardiology background,” Coletti says.

“The eCDI tool will also allow the CDIS’s to utilize electronic Clinical Documentation Worksheets, instead of paper worksheets, to capture their clinical data, fully automating data capture on the front end. This will enhance daily follow up and transfer of cases to another CDIS, in the event of illness or vacation,” says Coletti.

Finally, let’s not forget ICD-10

Not a surprising finding, but according to a 2010 ACDIS survey, 81% of respondents expect to see an increase in query volume when the new ICD-10 system is live. We believe having the query software in advance will make the transition on October 1, 2013 quite a bit easier for us at Memorial Hermann.

Editor’s Note: Anna Wheeler, at the time of this article's original release, was director of Coding Services at Memorial Hermann Healthcare System in Houston, Texas.