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Q&A: ACDIS advisory panel members answer questions about electronic records, POA

CDI Strategies, March 20, 2008

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Note: The following are answers that two members of the ACDIS advisory panel provided to members of the association.

Q: Do you know of any hospital that is using a CDI program with an electronic medical record (EMR)? We are in the process of implementing an EMR and finding out that queries in the electronic record can be overlooked by the physicians. The company implementing the EMR for us does not want our queries to be part of the permanent record. Do you have any advice for us?

A: We have a hybrid record. We use a paper worksheet with queries on it that goes in the paper chart. But we also use a software application to create the paper worksheet. Therefore, the queries are in an electronic format.

We were able to work with the people who administer the EMR and create a way to send the queries to the physicians by way of an "inbox" in the EMR (it's the same type of communication used to let them know that they have orders to sign). So the staff is able to copy and paste their queries from the electronic worksheet to the communication box in the EMR. This has helped us overcome the issue of docs missing the queries. We also do not leave the query in the permanent medical record. We feel strongly that the record should stand alone without the query to support the documentation.

(Tamara Hicks, RN, BSN, CCS, manager of care coordination, North Carolina Baptist Hospital, Winston-Salem, NC)

A: Why does the consulting company have any say about your queries? From a compliance standpoint, it can be an issue (which can be overcome), but that should be decided by your facility, not the consulting firm. Some facilities keep track of physician queries and use their response rates as part of their recredentialing process. Have you thought of using that angle to increase response rates?

(Lynne Spryszak, RN, coordinator, clinical documentation management program, Alexian Brothers Medical Center, Elk Grove Village, IL)

Q: Is it possible to find out in more detail how people are capturing present on admission (POA) data?

A: Our HIM/medical records staff run a report every two weeks with all of the POA ICD-9-CM codes identified by CMS as codes they will not pay for unless they are reported as POA.

Next, the charts that have these codes with an "N" (i.e., No, not present at the time of the inpatient admission), "W," (i.e., Clinically undetermined, the provider is unable to clinically determine whether the condition was present at the time of the inpatient admission or not), or "U" (i.e., Unknown, the documentation is insufficient to determine if the condition was present at the time of the inpatient admission) next to them are pulled for abstraction/review. Those charts with final "Ns" are entered into a database and reported monthly.

(Lynne Spryszak, RN, coordinator, clinical documentation management program, Alexian Brothers Medical Center, Elk Grove Village, IL)

A: We are running monthly reports to analyze the POA data. The cases flagged with "N" are reviewed again to determine if there are opportunities to clarify. We also have the staff reviewing cases after coding but prior to billing when the POA is:

a) Flagged as "N," "U," or "W."

b) One of the identified conditions that will not be paid after October 1, 2008, if the DRG is impacted.

The purpose of this review is to ensure that documentation is clear and to determine whether it needs to be clarified.
 
(Tamara Hicks, RN, BSN, CCS, manager of care coordination, North Carolina Baptist Hospital, Winston-Salem, NC)

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