Question

Overview

A medium-sized hospital had been using an EHR for 12 months. They were having great success with getting the providers to document within a timely fashion; however, many of the notes did not provide enough information to code the record and/or key components to adequately code were missing. They had a process for physician query, as follows:

Electronically flag the record for physician query

Create 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 chart to flag the provider of a coding query that needs to be completed

The provider comes into the HIM department to complete the query

The deficiency is removed, and the query is scanned into the chart

HIM operations then notifies the coder, through an e-mail, that the query was answered

Chart is coded and sent to billing

While it was a strong process and the providers did answer the questions, it caused a spike in the time to get the charts coded and to billing, 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 organization needed to change the process to help accelerate the query process and reduce the physicians’ frustrations of having to come into the HIM department.

New functionality exists within the EHR to send an electronic query, which would automatically assign the deficiency and send a note to the provider’s inbox within the EHR alerting him or her that a coding query exists. The new process had fewer steps and involved fewer people; however, the physicians were concerned about the new process. With careful training and education, the new process was implemented and reduced the steps, making the physician query process easier for coding, HIM operations, and the providers. The new processes steps were:

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)

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 chart then automatically flagged to complete coding

Chart 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 organization has significantly reduced the time it takes to code and bill all patient encounters.

1. Instructions: Respond to each of the three topics 50 words or more except Q2.

A. What are the benefits of an electronic-based query? What were the positive impacts made on this organization? Were there any negative impacts and why? (25 pts).

B. List the 10 characteristics of data quality found in the AHIMA data quality model (25 pts).

C. What else could the facility do to improve the query process? What are the resources needed (time, money, personnel, etc.) to facilitate these potential improvements? Would these be opposed by anyone involved in the process (for example, if something is going to cost too much, the hospital may not pay for it; or physicians might be opposed to anything that compromises accuracy, etc.)? (25 pts.).

Answer 1

Benefits Electronic based physician query:

Electronic based query is better than approaching with physician directly, most of physician

• Improve physician public profile
• Time saving
• Physician will get education where the document is lacking this will corrected in the future
• Paper free and ecofriendly
• Accurate calculation of Mortality index
• Improve patient care and quality
• Ensure accurate hospital timely billing
• Improve the quality of document
• Document was updated in timely manner

Positive Impacts:

• The Physician query was completed within 20 to 25 days and coded the chart its went to billing with in short period of time
• The new functionally feature of the query automatically alerts the physician with involvement of other peoples and sending mail to coder its saves much time in billing process.

Negative impacts: I don’t think there is a much negative things here

Data Quality management of AHIMA

1. Accountability
2. Transparency
3. Integrity
4. Protection
5. Compliance
6. Availability
7. Retention
8. Disposition

As per above organization medical record I have not seen any such scenario impacts AHIMA quality instruction