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The Clinical Documentation Conundrum

By smace@healthleadersmedia.com  
   February 01, 2017

The heart of the process is that the text-prompts workflow presents critical information to the clinician at the point of care, but does not overwhelm the clinician.

The Sparrow initiative was facilitated by a physician advisory group, led by physicians who directed the organization's efforts to spearhead the implementation and refined the usability of documentation queries, Zaroukian says.

On the technology side, Sparrow's leadership team also implemented the Optum Enterprise CAC platform for two of its hospitals. This technology reads clinical documents and creates lists of supported diagnoses. These diagnoses contain links to the patient's EHR, highlighting key words and phrases in each document.

Sparrow leadership learned the following from the case study:

  • Successful implementation with desired results requires understanding and agreement around business processes and how health IT systems can support them. One of the key success factors was identifying and overcoming communication barriers to ensure understanding and promote buy-in.
  • Executive level support and involvement were critically important to a successful CDI program.
  • Remember the value of Plan-Do-Check-Act (PDCA) cycles of improvement and continue to get feedback and fine-tune systems and processes after implementation.
  • Communicating the advantages and expected benefits to affected caregivers throughout the implementation process creates positive engagement, anticipation, and commitment.
  • Involving frontline caregivers during system build and testing helps ensure successful implementation, improved processes, and high user satisfaction.

ICD-10 falls short
In the year since ICD-10 replaced ICD-9 in the United States, it has taken its place as one tool in the toolbox to help make documentation more consistent, but a tool that has fallen short of its original promise to assist with CDI. "Some people would say it's helping; other people would say it's hurting the documentation," says Dean F. Sittig, PhD, a biomedical informatics professor at University of Texas Science Center at Houston's Health School of Biomedical Informatics and a member of the UT-Memorial Hermann Center for Healthcare Quality and Safety in Houston. "Right now most of the documentation is in free text, so it's not using ICD-10. There's a lot of inconsistencies there and a lot of problems there."

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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