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Getting ambitious with clinical documentation management

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  By Jonathan Elion, M.D.,  January 29, 2013

ValleyCare Health System transforms reporting and coding with innovative CDI software.

There is a shift currently underway within the healthcare industry. In a time when revenue and reimbursement rates, risk mitigation and avoiding RAC audit paybacks all depend on maintaining accurate records, computer-assisted clinical documentation improvement (CACDI) has increasingly become a focal point for hospital administrators, HIM professionals and physicians alike. The transition to ICD-10 only serves to further spotlight the importance of precise documentation. ChartWise:CDI is an all-inclusive CACDI software application that provides a proactive method for improving documentation in an efficient, systematic and sustainable manner via a clinically intelligent, easy-to-use tool.

When ValleyCare Health System determined that the documentation software currently in use was no longer meeting the needs of the not-for-profit health system, it was decided that a more sophisticated solution was required. ValleyCare Health System consists of two medical campuses located in the eastern San Francisco Bay Area housing 242 beds and more than 300 medical staff. The organization found that integrating a CDI program across multiple physical locations required advanced analytics and case management reporting that were not available through the existing vendor. ValleyCare also wanted to make a concerted effort to optimize reimbursement rates to enhance the financial well-being and growth of the company.

When it became apparent that a new CACDI software solution would be required for ValleyCare to execute its documentation improvement program successfully, Valerie V. Mendoza, RN, BSN, CCDS and lead documentation specialist with ValleyCare was tasked with selecting the new provider and solution. “We kept a variety of features and services in mind when this process began, and we knew that whichever provider was ultimately selected would need to have more than just a basic data entry program,” says Mendoza. “We knew this was our opportunity to be ambitious and establish a truly effective CDI program. Training, technical support, advanced analytics and increased reimbursement were all on our checklist of features/services we wanted to emphasize.”

Detailed case management reporting was at the top of Mendoza’s list as she began to test various CACDI options. She envisioned distributing a report to the case management staff in hopes that they would bring awareness to physicians about the length of stay of their patients and to proactively discuss care and discharge plans. With ChartWise:CDI, she could receive a daily snapshot of the length of patient stays, providing a vehicle through which case managers can hold those discussions with physicians. These reports could be generated daily and sent to each case manager for use during their morning rounds with the multidisciplinary team, ultimately helping ValleyCare improve patient care and reduce expenses.

“We did our due diligence in the process of selecting a new CDI provider and brought in a handful of organizations to demonstrate the value of their software,” says Mendoza. “However, we could tell early on in the process that ChartWise was the most comprehensive program with the most impactful functionality on the market.”

 In addition to the case management reporting, ValleyCare has been particularly impressed with the ability to run reports on demand that help them manage and monitor their CDI program. The ValleyCare daily CDS Impact Report allows the organization to aggregate a running total of the financial impact resulting from the new CDI program and follow its progress continuously. This feature has helped ensure the revamped CDI program is making a significant positive impact with regard to reimbursement. Previously, the Bay Area health system only had access to quarterly figures. ChartWise’s software also provides ValleyCare with suggestions for differential diagnoses, RAC alerts, the AHA Coding Clinic guidelines and crosswalk functionality between ICD-9 and ICD-10.

As ChartWise’s CACDI software application became the clear-cut choice for ValleyCare’s CDI program, the focus shifted from vendor selection to implementation and training. The ChartWise support team had ValleyCare up and running in approximately one week, and the open dialogue between the documentation software supplier and health system personnel facilitated the process. “ChartWise’s support staff is always eager to help and virtually never tells me they are unable to do something,” says Mendoza. “Early on in the implementation process, I had quite a few requests for changes to address our facility’s unique needs and patient population and ChartWise was able to meet our requirements. I cannot express enough how great the customer service was during the transition phase, not to mention currently.”

“Teaming with ValleyCare Health System to introduce our new approach to documentation improvement has been a tremendous experience and opportunity,” says Mary Cooper, executive vice president of ChartWise. “The synergy between the two organizations has been remarkable, and ValleyCare’s patients, physicians, CDI program team members and hospital administrators will ultimately benefit from the results.”

About the author

Jon Elion, M.D., is the founder of ChartWise Medical Systems, a Rhode Island-based company that designs innovative, hosted software solutions for hospitals. Their premiere product, ChartWise:CDI, is the first-to-market interactive software system designed to improve precision in quality clinical documentation to support revenue assurance. Dr. Elion is a practicing board-certified cardiologist in Providence, R.I., and an associate professor of medicine at Brown University. Learn more at www.chartwisemed.com.


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