Last month I focused on training practitioners in documenting appropriately for ICD-10 and ensuring that training is focused on the right specialty. I mentioned the template rebuilding necessary to support ICD-10 documentation requirements. Many of my hospital systems and physician practices are now beginning the template and workflow revisions. We don’t have much time left – only about 4-5 months to review, create, and/or rebuild workflows and templates. We also have to allow time for testing and revisions in addition to rebuilding.

 

From an operational perspective, how do you accomplish such a monumental task? Vendors typically provide basic workflows and template designs to clients. It is up to each organization to build additional, customized templates or workflows. Many of you have customized your electronic health record to suit the needs of your organization. In preparation for ICD-10, updating or rebuilding these workflows and/or templates is critical. Making certain we are capturing the required data so we can code and submit claims properly is important. Some key considerations include:

  • Regulatory requirements
  • Documentation

  • Coding

  • Quality measures

  • Patient safety

  • Continuity of care

  • Medical necessity

Templates can assist in standardizing information or elements of clinical documentation. Templates and workflows must be user-friendly and capture required documentation in an efficient manner. It is also important that each template or workflow operates in a fashion that is not time-consuming, which can be frustrating to practitioners or staff members. When looking at progress note templates, it is important to include updated diagnoses and procedures. For example, if the templates are tied to a certain type of patient, such as diabetics, the template must include type, manifestation, insulin usage, and other elements in order to allow practitioners to arrive at the appropriate diagnosis codes. Some templates are otherwise tied to procedures or other clinical indicators.

The first step of the rebuilding process involves selecting a core group of people to serve on a template/workflow rebuilding subcommittee. Who should sit on this subcommittee? It is important to have key personnel from various areas, including (but not all-inclusive):

  • A chairperson with an extensive understanding of workflows, templates and operational processes

  • Physician champion

  • Coding professional

  • HIM professional

  • Information systems

  • Clinical professional (RN, LPN, therapist, etc.)

  • Patient financial services professional

  • Registration manager or director

  • Compliance professional

  • Clinical documentation improvement practitioner

Having clinicians involved ensures that data supporting quality of care and proper documentation is captured to adhere to ICD-10 requirements as well as meaningful use. The process can seem daunting if you have hundreds of workflows and templates that you must work through. Yes, this can be time-consuming, but through having a solid subcommittee and dividing the workload, it is manageable. However, it still will take several months to complete the process, especially for a larger organization.

What is the first step in this process, beyond creating a subcommittee? Have your information systems department identify all the templates, by department, that contain clinical documentation, a diagnosis description, or a diagnosis code. List all the templates in an Excel spreadsheet and identify all departments that use each template, along with the purpose of each.

The next step is to narrow down the templates that do not contain diagnostic information or documentation that is critical to supporting ICD-10, and eliminate them from the list. Then develop a checklist for the committee to work through. Here is an example of what questions might be helpful to review prior to rebuilding or creating new templates (list is not all-inclusive):

  1. What elements in the template or workflow are critical in supporting medical necessity?

  2. Is the template a duplicate, or similar to another template that can either be duplicated or eliminated?

  3. Are the workflow/template titles duplicates, or similar to other templates or workflows?

  4. Are standard abbreviations used, or do they need revision?

  5. Do any of the items contain abbreviations from the “do not use” list?

    1. Sometimes practitioners develop their own abbreviations that are not standard; these should be eliminated.

    2. Check to be sure that all acronyms are used correctly.

  6. Does the template contain diagnostic data, such as codes or descriptions?

  7. Is the format of the template appropriate?

  8. Does the documentation in the workflow/template appear logical, or does it need revision?

  9. Are there required fields in the template, or do required fields need to be added, particularly in the practitioners’ progress or chart notes?

  10. Is there a pick list appended to the template?

  11. Does the workflow/template need to identify gender?

  12. Does the workflow/template allow for free text, or is it based on check boxes or selection (and if not, should free text be added, or should check boxes be added?)

  13. Does the note title follow the established hierarchy or mapping mechanism?

  14. Is the intent of the template/workflow to trigger an alert to the practitioner (ABN, advance directives, etc.)?

  15. Are there built-in default values that may trigger inappropriate or erroneous information in the documentation that need to be eliminated?

Once you have narrowed down a protocol and the templates that will require review, it is a good idea to divide and conquer. Assign a specific number of templates to each committee member. Make sure you record who is reviewing what. Once you assign the templates, it is important to schedule meetings with departments or individuals who use the templates to review the templates/workflows, how the department or individual uses them, what works and what needs improvement, etc. Another set of key issues is how the templates or workflows are applied in other areas, whether they interface with a coding queue, and whether they intersect with other workflows or templates (or other software applications). Give the committee members a reasonable deadline for completing their assignments.

Once each team member reviews his or her assigned templates or workflows, it is recommended that each member present each template to the subcommittee to review the elements and to either approve or begin rebuilding. Information systems and/or the person responsible for template rebuilds within the organization must be available during this process to identify any barriers or challenges to the rebuilding process. In addition, I also recommend that you have a staff person or clinician present from the relevant departments or areas during these meetings to explain how each template is used.

Each time you rebuild a template, placing it in a test environment and having a staff member or practitioner who uses it test and approve it is a key success element when rebuilding templates for ICD-10.

Conclusion

It is understandable that this might seem like a daunting undertaking, but with proper planning, organizational efficiency, and diligence you can achieve success – along with making improvements to your EHR. This is an important step toward ICD-10 compliance.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and a recognized national speaker, consultant and American Medical Association Author who has been working with ICD-10 since 1990 and is the author or Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10 and the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA.  She is a senior healthcare consultant with Karen Zupko & Associates.  Deborah is also the 2017 American Health Information Management Literacy Legacy Award Recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.