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Tip: Use technology to improve your CDI efforts

CDI Strategies, September 25, 2007

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Technology is an important consideration when launching a clinical documentation improvement program, or when you're trying to find ways to improve an existing programs' performance. Some technology to consider includes the following:

• Horizon Business Insight, McKesson. This product is helpful because you can narrow down your complication/comorbidity capture rate or case mix index by service, says Colleen Garry, RN, BS, clinical documentation manager in the health information services department of the Medical University of South Carolina in Charleston. "You can narrow it down and audit based on DRG assignment.

  The program even allows you to rank individual physicians' data scores. For example, Garry can pull data on all the attending physicians in cardiology and what each individuals' CMI and CC capture rate is. "This might be of interest to a department chair, because all the physicians' data should be more or less the same over a period of time," Garry says.

• Encoder (any make). While an encoder is obviously a must for every coder, Garry says they can prove to be invaluable teaching tools for a physician.

  Using her facility's 3M encoder, Garry will roll a case through for physicians. This often proves to be an eye-opening experience for physicians as to the level of detail necessary to code an inpatient stay, and can lead to sympathy for the coders' job and a greater willingness to document to a higher level of detail.

  "Physicians typically react with, 'I didn't know it prompts you with all these questions,'" Garry says. "They're amazed with the level of specificity ICD-9 codes entail."

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