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The Clinical Documentation Conundrum

   February 01, 2017

"This kind of process was laborious and only partially successful on paper," says Michael Zaroukian, MD, vice president and chief medical information officer of Sparrow Health System, anchored by its 676-licensed-bed teaching hospital in East Lansing, Michigan. The CDI picture brightened when EHRs and accompanying decision support arrived in the form of Claro CDR software for CDI workflow, allowing Zaroukian's team of developers to "make that information available to various health professionals in our organization to decide, for example, which patients might need greater services at discharge to help either prevent readmission or to help them with an improvement in their quality of life," Zaroukian says.

"We did consider it to be part of our approach to making sure we had a better understanding of the total complexity of our care, so that we could then use it to inform other aspects of the tools we use to adhere to best practices, decrease unnecessary variation, and promote improvements in patient care, outcomes, and satisfaction."

In a 2015 HIMSS Analytics Stage 7 case study, Sparrow reported that these CDI efforts yielded $5 million in additional revenue from September 2013 to December 2014, due to increased case-mix index resulting from CDI and computer-assisted coding-supported workflows. Sparrow retired paper CDI queries and replaced them with in-basket EHR messages that made CDI query delivery and physician replies easier and more efficient.

Additionally, physician response rate to CDI queries increased from a baseline of 60% to 92% after implementation of EMR-supported CDI and CAC processes. These processes are now completely electronic, and contributed to Sparrow's CDI specialists being able to move from 80% to 100% review of Sparrow charts, without requiring additional specialists.

Sparrow leadership realized that technology would help with better documentation, so it augmented its Epic EHR with templates, which presented clinicians with cascading text prompts to achieve that greater specificity without a CDI specialist actually looking over their shoulder, Zaroukian says. "As we were getting ready for ICD-10, there was a recognition that just putting an EMR in place and just asking people to document better, using what we've educated them upon in the past and asking them to remember all that and to somehow take time from their busy world in a non-workflow-integrated way to improve their documentation, was not having any significant effect."

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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