It is a constant challenge for health information management (HIM) departments to identify ways to improve the clinical documentation they receive from care providers, so they can perform their jobs more efficiently and effectively. Poor documentation results in slow downs and backlogs in HIM, and has a ripple effect throughout the entire hospital, ultimately leading to decreased compliance, greater liability, and potentially sub-optimized reimbursement. ChartWise:CDI is a comprehensive software tool that provides a proactive method for improving work efficiency, compliance and reimbursement through improved documentation and reporting.
When Starla Stavely-Dill, RHIA, became the HIM director at Jennie Stuart Medical Center (JSMC) in Hopkinsville, Kentucky, her initial assessment of key financial & coding data revealed opportunities in their clinical documentation. Statistics indicated that the diagnoses and procedures being documented by clinicians were not reflective of the severity of illness of their patients or of the length of stay. As a result, the case mix index was below expectations for the type of patients being treated at JSMC. Additionally, most of the medical staff at this community hospital was unaware of the impact their documentation had on both compliance and reimbursement.
Search and Action:
JSMC began an extensive search for a CDI vendor, and while numerous traditional consultant-based models were evaluated, all required lengthy and expensive engagements. As a community hospital with roughly 200 beds and limited resources, JSMC needed a unique approach. “Within the first 15 minutes of the ChartWise demo, we knew we were seeing something that could provide a solid foundation for our program”, states Stavely.
ChartWise Medical Systems, Inc., is a new and innovative clinical documentation improvement software company from Rhode Island. The focus of the ChartWise software is to provide an immediate solution to clinical documentation specialists, case managers, quality teams and caregivers, by assisting in improving documentation via a clinically intelligent and easy-to-use tool. For JSMC, it provided an affordable, sustainable, and effective clinical documentation program.
The hospital CDI committee saw immediately that ChartWise was offering something different from anything else in the market, but the deciding factor for the committee was the evidence of the built-in clinical intelligence. In his presentation to the medical center, Dr. Jon Elion, M.D., the firm’s President/CEO, founder, developer, and practicing cardiologist, demonstrated how the expert information embedded in the ChartWise system reviews existing diagnoses, procedures, lab values and medications, and offers additional diagnoses for the clinical documentation specialist to consider, resulting in a more accurate, complete and clinically significant summary of diagnoses and procedures. Along with this built-in expertise, the software provides standard and customized electronic queries that help eliminate ambiguity and inconsistency, and increase compliance. ChartWise also takes CDI tracking and reporting to a new level, with—robust, on-demand reports that provide immediate actionable metrics to program managers and hospital administrators.
Top Notch Solution and Service:
Since ChartWise is a web-based solution, the implementation, including an HL7 ADT demographic feed interface, was much faster, simpler, and less expensive for Jennie Stuart than other systems would have been, taking the burden away from the IT department. “It took less than two weeks for the ADT feed to become functional, and we were up and running,” noted Starla. “ChartWise provided the clinical expertise immediately and allowed us to implement quickly and efficiently.”
She went on to say that “access to ChartWise support staff has been great. They are always available and extremely knowledgeable. We have a great relationship with them and have benefitted tremendously from their expertise. The webbased product, turnkey solution, and price for value combined to make this an easy decision for senior executives as well.” She notes that the selfcontained, flexible reporting tool has helped the facility identify positive changes in case mix, and helped identify opportunities for future education.
“We couldn’t have found better partners than Starla, her staff, and Jennie Stuart Medical Center, says Mary Cooper, Vice President of ChartWise. “Starla knew what she needed for her documentation improvement program, and started the wheels rolling for a successful implementation. It’s very rewarding to see a happy customer, and to see the software working effectively to improve their clinical documentation so dramatically.”
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