A medium-sized hospital had been using an electronic health record (EHR) for 12 months.

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.

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