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1 Problem List Centric CDI Workflow: Better Care Through Communication in the Age of the Electronic Medical Record Sheilah Snyder, MD, FAAP Physician Champion CDI, Pediatric Hospitalist Marietta Morhardt, BSN, RN, CPN, CCM CDI Specialist Children s Hospital & Medical Center, Omaha, NE 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify benefits and disadvantages of various EMR based CDI workflows Describe the workflow of using BestPractice Advisories (BPAs) as a communication tool for a CDI program clarification Assess the goals and metrics of a successful pediatric CDI program 2 Children s Hospital & Medical Center Smallest town in U.S. with 2 med schools 145 beds Total patient visits in 2015: 450,000 Inpatient admissions: 8,200 Specialty clinic visits: 94,000 General pediatric clinic visits: 210,700 Children served in pediatric clinics: 88,400 Emergency & UC visits: 48,300 Critical care transports: 1886 Surgery cases: 12,400 3
2 Provider Communication CDI Clarifications Traditional methods have not been terribly successful Epic EMR Sticky notes Inbasket messages CDI specific note type 4 Sticky Notes 5 Inbasket Message 6
3 Inbasket Message 7 Provider BestPractice Advisory (BPA) 8 Provider Communication Why BestPractice Advisories (BPAs)? Implementation of EMR automation to help improve CDI process BPA is an alert that can be addressed when the provider opens the chart Problem list based note templates 9
4 Provider Communication BestPractice Advisory CDI Clarification CDI RN review of all inpatient charts, re review weekly, follow up on all clarifications Daily in person attendance at rounds by CDI RN for live feedback, with subsequent documentation in EMR for tracking purposes 10 Building a BPA 11 Building a BPA 12
5 CDI Clarification From BPA to Note 13 Provider s View BPA 14 Problem List Browse Common Diagnoses 15
6 Problem List Preference List 16 Problem List Database Lookup 17 Progress Note Template APSO format for all notes Problem list based assessment Still requires the provider to address each problem in the plan, which is free text entry Note can be copy forwarded for next day but needs to be updated Problem list is updated every day in rounds 18
7 Progress Note Template 19 Progress Note Template 20 BPA Provider Workflow 21
8 BPA Provider Workflow 22 BPA Format Advantages High response rate Quick response time Utilizes problem list centric note templates Standardization of documentation format Able to quickly gain data from verbal interactions during rounds Disadvantages CDI clarification directs provider to update the problem list that flows into the note template. This is simply a reminder to the provider that they still need to address this problem in their plan. 23 CDI Nursing Review Process 1. Review queue that includes patients admitted hrs prior (inpatient only not reviewing observation at this time) 2. Round daily with providers on a rotating schedule 3. Send out BPA clarifications as needed 4. Follow up on previous day s clarifications/may call or if no change or response 5. Educate as needed and opportunities arise 6. Will refer providers to physician champion if repeated lack of response to clarifications sent 7. Meet regularly with physician champion to review any issues with process or clarifications 24
9 Top CDI Clarifications at Children s 3% 12% 18% 28% Intellectual Disability 28% Acute Resp Failure 9% Chronic Resp Failure 3% 9% Malnutrition type 27% 27% Obesity 12% Anemia type 3% 3% Other 18% CDI BPA Results 652 BPAs sent Response to BPA questions in EPIC: Accept: 348 (53%) Disagree: 26 (4%) No response: 278 (43%) BPA questions not always answered, but usually the changes are made in the problem list and documented in the notes Goal agreement with clarification: 80%, which means they made the documentation changes 26 National CMI Data From PHIS 27
10 Omaha Children s Case Mix Index Source: PHIS 28 Financial Impact of CDI on CMI 29 Next Steps Standardization of note templates Data review for additional documentation improvement opportunities Reviewing observation patients, outpatients Educational opportunities: new providers, midlevels, new residents CDI reconciler bridging the HIM/CDI relationship Pediatric definitions that are widely accepted nationally: Acute resp failure 30
11 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 31
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