Reference no: EM133304800
Case Study: A medium-sized hospital had been using an electronic health record (EHR) for 12 months. It was having great success in getting the providers to document within a timely fashion; however, many of the notes did not provide enough information to code the record or key components to adequately code diagnoses and procedures were missing. The hospital had a process for physician
query, as follows:
?? Electronically flag the record for physician query
?? start a paper query form for the provider
?? Send the electronic query to the HIM operations department to put in a physician completion folder
?? HIM operations adds a deficiency to the patient health record to flag the provider that a coding query needs to be completed
?? The provider comes to the HIM department to complete the query
?? The deficiency is removed, and the query is scanned into the health record
?? HIM operations notifies the coder via e-mail that the query was answered
?? The health record is coded and the codes are sent to billing. While it was a strong process and the providers did answer the questions, it caused a spike in the amount of time it took to get the health record coded and billed, as providers usually came into the department once every 20 to 25 days. In some cases, providers would leave the coding queries unanswered for up to 60 days. The average turnaround time for a coding query was 28 days. The hospital needed to accelerate the query process and reduce the physicians' frustrations with having to come to the HIM department. New functionality within the EHR was used to send an electronic query that automatically assigned the deficiency and sent a note to the provider's inbox alerting them that there was a coding query. The new process had fewer steps and involved fewer people; however, the physicians were concerned that the additional time required to learn the new process and system was impacting time spent with their patients. With careful training and education, the new process was implemented and reduced the steps, which made the physician query process easier for coding, HIM operations, and the providers. The following are the new process steps:
?? Electronically flag the record for physician query
?? Create the electronic physician query through predesigned templates and assign the correct physician (this would automatically assign the deficiency and send the coding query to the inbox)
?? The physician electronically completes the coding query through the EHR
?? The electronic deficiency is automatically removed, and the coding query is electronically submitted to the physician and retained and the health record then automatically flagged to complete coding
?? The health record is coded and sent to billing. With the change in the process, the HIM operations department has little involvement unless it is supporting the physician in completing the query. The turnaround time for completion of coding queries was reduced from 28 days to 15 days within the first 60 days of completion. The process was a success and the hospital has significantly reduced the time it takes to code and bill all patient encounters.
Questions:
1- Examine the use of the electronic-based query and identify positive impacts that it made on the healthcare organization.
2. Critique their strategy for addressing documentation issues.
3. Recommend something else that the healthcare organization could do to improve the query process.