Reference no: EM133443560
Real World Case 1
Certain members of the executive management team at ABC Hospital are interested in adding voice recognition software to their current EHR. As director of HIM, Cynthia is preparing an extensive report on the impact this would have on the department. She is proposing that a feasibility study and subsequent request for proposal be completed.
The report includes information on voice recognition such as the projected workload of voice recognition software and how it would be implemented in the daily EHR operations. This includes its usage for the standard transcribed reports, such as discharge summaries; histories and physical exams; operative, autopsy, and consultation reports; physician progress notes; nursing care documentation; and other therapy documentation. A review of historic and current transcription workload, number of staff with respective salary and benefits, supplies, and equipment is completed.
One of the objectives Cynthia has made is to interview HIM directors at other hospitals who use voice recognition. She wants feedback on how it changed the HIIM functions within the department and the hospital. In addition, she wants to know how this software affects the quality of the generated reports and how much time is invested in report editing by the staff. The physician query process is another area that she wants to scrutinize. The transcription supervisor is also trying to determine what criteria and updated skills will be needed in the retained employees. The human resources department was consulted regarding the process of lay-offs for some of the staff whose positions are not upgraded.
1. Recommend changes need needed to change the job description of a transcriptionist to an editor for transcribed reports.
2. Identify job retraining to be offered to transcriptionists whose positions are eliminated due to the implementation of voice recognition software.
3. Develop a list of questions to be addressed at site visits to evaluate different voice recognition systems at various healthcare organizations.
Real-World Case 2
At ABC Hospital, as part of the Health Information Management Department's quality initiatives, a multidisciplinary approach is being established to ensure the quality of data management and its use for organizational objectives. All activities need to emphasize one (or
all) of these three areas: clinical aspects, administrative applications, and population health monitoring. Quality documentation management is essential for all of these endeavors and will be applied to the following.
Clinical documentation improvement (CDI) will address the clinical aspects with a team of nurses, ancillary staff (therapists, lab, radiology, etc.), physicians, and HIM coding staff. The increased need for clinical documentation specificity to meet ICD-10-CM/PCS requirements and quality reporting indicators for CMS, TJC, and other regulatory agencies makes this aspect to warrant more resources, time, and personnel to meet the quality objectives.
Computerized-assisted coding (CAC), working in conjunction with CDI, will help the Coding Staff better analyze documentation for more detailed ICD-10-CM/PCS and CPT code assignments in a more efficient manner. This, in turn, will facilitate the completion of grouping
(inpatient and outpatient), getting the completed codes to the billing staff in an expedited manner, and statistical reporting of diagnoses and procedures as necessary.
Health information exchange (HIE) will assist in addressing population health monitoring. By strengthening the transmission of patient data to their outpatient care partners, ABC Hospital's goals are to increase the health of the community by offering additional services depending upon their needs. There has been an increase in the number of retirees who have relocated to the area, the African-American population is significantly higher than the national average due to a historically black university/college located within the county, and a fluctuating
student/young-adult population due to four large universities and colleges within the city limits.
Health services that address cardiovascular, cerebrovascular, endocrinology, emergency services, and family practice are being analyzed and improved based on statistical trends.
1. Identify at least three questions/concerns about the CAC system that the coding staff will have.
2. Describe the role of HIM professionals in population health reporting.
3. Explain how CDI functions will improve reimbursement.