As Medicare reimbursement standards tighten and projected losses in productivity associated with ICD-10 conversion loom larger, HIM professionals, hospital administrators and industry decision-makers are realizing that Computer-Assisted Coding (CAC) solutions alone won’t suffice in meeting the specificity of documentation required under ICD-10. An impactful, comprehensive Computer-Assisted Clinical Documentation Improvement (CACDI) program can significantly enhance a coder’s documentation efficiency while ultimately impacting the organizations’ bottom line through optimized reimbursements. The ChartWise:CDI solution from CACDI software provider ChartWise Medical Systems includes state-of-the-art functionality which allows the user to ensure proper documentation is always maintained by way of an intuitive, easy-to-use interface designed to streamline the documentation process for clinical documentation improvement specialists, coders and physicians alike.
Gwinnett Hospital System, Inc. provides a wide array of high-quality services to the Lawrenceville, Duluth, Johns Creek and Atlanta areas of Georgia. With 553 beds, 800 affiliated physicians and 4,100 employees, Gwinnett Hospital System, Inc. has developed an exemplary CDI program and ranks in the top five percent nationally for clinical quality. However, up until early this year the organization had been using the same software tool since the program’s inception in 2004, and that software could no longer support the needs of their staff.
Gwinnett Hospital System, Inc. required a tool that would streamline workflow by automating manual processes. They also needed a platform capable of providing advance metrics and more efficient reporting. They were looking for a state of the art software solution designed to handle present and future documentation challenges associated with reimbursement, RAC audits and the ICD-9 to ICD-10 conversion. Coders needed to be able to query physicians electronically for speed, efficiency and accurate record keeping. However, the most salient attribute they required from their CACDI software to move the program forward was a user-friendly interface and an overall easy-to-use platform. The hospital system didn’t have the time or resources to execute extensive training with physicians and needed to make certain any advanced features contained within the software would improve efficiency for the hospital systems’ CDI and IT staff.
Search and Action:
When the decision was made to research and select a new CACDI provider, Maria Mann, clinical documentation integrity manager and RN, BSN, MSHL, CCDS, CCS with Gwinnett Hospital System, Inc., set out to find the most innovative, comprehensive, user-friendly CACDI software solution available to integrate into their CDI program. She invited the top vendors in the field to make a presentation demonstrating the value and functionality of their software.
“Once we reached the point of working through each software solution’s user functionality and integrative capabilities, it became readily apparent that there are no other tools on the market today offering what ChartWise:CDI does,” said Mann. “We were searching for the most user-friendly solution and that’s what drew us in, but ChartWise’s advanced reporting capabilities were extraordinary and we knew they’d be a tremendous resource for our CDI staff. We also found that the ChartWise software would help facilitate our transition from ICD-9 to ICD-10 and that their solution would streamline our workflow while increasing productivity.”
In the first five months since implementing ChartWise’s CDI application, the results have been significant. In January 2013, the month preceding implementation of ChartWise’s software solution, the CDI staff at Gwinnett Hospital System, Inc. engaged in a total of 774 initial chart reviews searching for any further documentation that could alter the severity of illness/risk of mortality or DRG, along with 439 follow-up reviews to see if the physician had answered their clarification query. In March 2013, the first full month since assimilating the new CDI program, the same team was able to complete 1,445 initial reviews and 1,850 follow ups, an increase of 87% and 321% respectively.
Furthermore, Gwinnett Hospital System, Inc. has seen a substantial increase in physician response rate since integrating the ChartWise:CDI software. In 2012, the average response rate was 75 percent. In the months since implementing ChartWise (February – May 2013), the average physician response rate has risen to 86.8 percent. Mann attributes the increase to the quality and content of the queries along with the ability to easily respond to a query.
“The entire process has been an overwhelming success,” said Mann. “From the easy-to-use interface, to the reporting capabilities, to the electronic query functionality, the transition has been seamless. I’ve seen just about every CDI software solution available and ChartWise’s tools as well as their team are light years ahead of the rest.”
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