October 9, 2012

Let’s Get Started: 10 Steps to Engage Physicians in Clinical Documentation Necessary to Support the Transition to ICD-10

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As I discussed last month, engaging your physicians in the transition to ICD-10, despite your best efforts and months of planning, may continue to seem a daunting task – a notion fueled by the recent delay, peer skepticism and a lack of focus on a requirement that won’t be implemented until 2014. Furthermore, in an effort to bring physicians into the fold, many industry, professional and trade associations have downplayed the impact in order to increase buy-in.

In my travels across the country, I am told by many physicians that their organizations are trying to shift the burden of coding to busy clinicians working at the point of care, a plan being executed under the guise of the elimination of superbills and charge sheets. The most common complaint I hear from physicians is that their organizations are requiring them to attend Web-based training courses on ICD-10, sessions that are far too time-consuming and much more in-depth than what they truly need.

If your physicians are bolting toward the nearest exit each time you mention ICD-10, perhaps it is time to rethink your strategy and prepare an approach similar to the one recently unveiled by Nicholas Holmes, MD, and this writer at the ICD-10 Summit last April. The plan featured 10 steps to increase physician engagement in order to assure a successful implementation:

  1. Assess the current physician documentation workflow.

  2. Outline the future state of clinical documentation to support ICD-10.

  3. Perform a coding and documentation gap analysis.

  4. Perform an impact analysis.

  5. Set realistic expectations and timelines to remediate documentation capture shortfalls.

  6. Develop a marketing and communication plan.

  7. Prepare a training plan.

  8. Identify strategies, solutions and/or refinements.

  9. Develop a budget.

  10. Prepare a transition road map.

As you approach the first step, it is critical that you brush up on information regarding the current workflow associated with clinical documentation capture and identify what the present choices as it pertains to capturing patients’ Diagnoses. Most organizations use a variety of methods, and many have not transitioned to a fully electronic record (some still are utilizing a hybrid record). Below are the most common methods of collecting diagnostic and procedural input:

  1. Utilization of a niche system problem list (SNOMED CT is mapped to ICD-9-CM) that interoperates within an electric health record system environment.

  2. A pick list, which features a pre-populated, shorter list (often referred to as a preference list) of packaged terms from which to choose.

  3. Free text of diagnostic and procedural information, either handwritten or electronically entered into a progress note, with a history and physical or discharge summary.

  4. Use of dictation and speech recognition software, which are still a common method – many of the speech recognition systems interoperate nicely within an electronic health record.

  5. Direct entry into EHR templates, utilizing many of the approaches above.

Following the identification of current practices and evaluation of provider satisfaction with current documentation tools and the technology, efficiency and effectiveness of each approach, the next step is to determine the gaps and opportunities to create an optimized future state.

Next month’s article will continue the journey and provide details regarding the execution of each step.

About the Author

Cassi Birnbaum, MS, RHIA, CPHQ is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.

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Read 57 times Last modified on September 23, 2013
Cassi Birnbaum, MS, RHIA, CPHQ

Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.