Health Information Management

Ten reasons for adopting an electronic query process in your CDI program

CDI Strategies, March 5, 2009

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Many clinical documentation improvement programs remain true to the paper query. Who could envision the death day of the “purple sheet” or “pink sheet,” as some facilities call their query form? But with the federal government promising an intense infusion of funds for health information technology, that day could be on its way.
 
Need more convincing to consider using an electronic health record in your CDI program? Barbara Hinkle-Azzara, RHIA, chief product strategist for Meta Health Technology, a HIM software developer based in New York, outlined her top 10 incentives to move ahead with an electronic query format.
 
1. Streamlined queries: Implementing an electronic system necessitates an analysis of your facility’s current query procedure.  This presents the opportunity to identify and prioritize bottlenecks and move to eliminate query process issues.

2. Improved documentation legibility: Ever struggle with illegible physician notes? With an electronic query process, physicians answer queries electronically so the response is legible instead of hand-written communications that are often difficult to read and interpret.

3. Stepping into the electronic medical record (EMR) era: An electronic query process takes you one step closer to a complete EMR system. In it, the physician can provide any clarification or specificity on the case by creating an electronic document that you can link to the patient’s EMR and make it available as a permanent part of the medical record. 

4. Growing physician satisfaction: Physicians often complain about time constraints. They’re too busy with patients to handle duties such as documenting in the medical record. Allowing physicians to respond to queries electronically requires a lesser time commitment, and increases their satisfaction with the overall clinical documentation improvement process. 

Additionally, sending the queries electronically allows the physician to answer the query remotely, saving him/her a trip to the facility to answer the query and/or document in the record.
 
5. Reduced manual follow-up responsibilities: Electronic systems allow you to automate reminders to physicians. This reduces the amount of time staff members spend tracking down physicians by phone or in person.
 
6. Increased staff productivity: By reducing the time staff members spend on the query process, an electronic system allows CDI professionals to focus on performing additional daily record reviews.
 
7. Improved reimbursement turn-around time: Similarly, if the electronic query can reduce the time spent chasing physicians on queries (both concurrent and retrospective) it can also reduce or eliminate related delays associated with incomplete records. 
 
8. Enhanced medical record documentation quality: Gains in efficiency with an electronic query process improves the content and quality of the medical record at time of discharge.
 
9. Heightened tracking and monitoring capabilities: Using an electronic physician query process makes your query data more accessible and allows you to track your facility’s key metrics, such as query volume, query rate, and query response rate. When you have this data electronically, it provides you with more time to analyze the results and work on performance improvement efforts.
 
10. Increased respect for your CDI program/query process:  Reporting collected data to administration and other key stakeholders builds recognition and respect for your CDI program and/or query process. After all, you need to get the credit you deserve for your CDI program success!
 
Editor’s note: Barbara Hinkle-Azzara, RHIA, chief product strategist for Meta Health Technology Inc., a HIM software developer based in New York, wrote this tip. Prior to joining Meta, she served as the Director of HIM at three acute-care teaching facilities in New York City. Contact her at bhinkazz@metahealth.com or visit www.metahealth.com



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