With the ICD-10 conversion deadline right around the corner, healthcare professionals are doing all they can to make sure they are prepared for the transition. Computer-Assisted Coding (CAC) solutions alone will not be able to meet the specificity of documentation required under ICD-10. The need for a comprehensive Computer-Assisted Clinical Documentation Improvement (CACDI) solution to ensure accurate records, improve outcomes and ensure equitable reimbursement is in high demand.
Southeastern Ohio Regional Medical Center recently addressed this issue. The medical center opened its doors in 1952 as Guernsey Memorial Hospital, named after the county it serves. Since then, it has served as Guernsey County’s onlygeneral acute healthcare center and largest employer. A true community hospital, “Southeastern Med” is affiliated with 180 physicians and is licensed for 99 beds. It has a coding staff of seven, along with four clinical documentation specialists.
When Denise Stephens, director of documentation integrity/utilization management, started as a documentation specialist four years ago, all documentation at medical center was on paper. Over the years she developed an Excel spreadsheet to track queries and create monthly graphs for her director and vice president. While it worked fine, the documentation team was also aware of the opportunities on which they were missing out and the information they were unable to provide.
Search and Action
Amidst her search to find an application to assist the clinical documentation specialists at Southeastern Med, Stephens attended the 2012 Northern Ohio Documentation Specialist meeting where she learned about ChartWise and later called for a demonstration of his company’s software.
For Stephens and her team, ChartWise was the clear choice. Their willingness to work with a small community hospital, the affordability and the ability to import data via HL7 feeds helped them stand out from other vendors.
Stephens took the ChartWise software to the medical center’s Purchase Analyst Support Team and pitched them on the software’s return on investment (ROI), ease of use, ability to toggle from ICD-9 to ICD-10, and the minimal internal support needed from the medical center’s IT team. Important to Stephens was the ability to demonstrate to our CEO that ChartWise could help the staff accomplish more, improve the quality of care, and supplement the hospital’s needs.
Stephen said, “In our case, the addition of the documentation system promotes the quality and integrity of care received, a decrease in medical necessity denials, and more accurate coding. These do not necessitate reimbursement figures but assist in our HVBP (hospital value-based purchasing), APU (annual payment update), and validation with CMS (Centers for Medicare and Medicaid Services).”
Once ChartWise was selected, implementation went quite smoothly, Stephens says. The ChartWise implementation team and trainers worked closely with Stephens and her team, preparing them for their go-live.
Southeastern Med implemented the ChartWise software in September of 2014, and in the first three months, the medical center’s query impact captured more than the previous nine months combined. Other improvement reported by Southeastern Med are ease of use, time saved, excellent support, and being able to test and easily transition from ICD-9 to ICD-10.
When asked about her favorite ChartWise 2.0 features, Stephens says, “We love the program’s Sophie built-in intelligence feature which helps guide the staff through queries and consideration of other diagnoses. Then, there’s the baseline to working DRG and the ease of review, thanks to features like color coded notes. In the past, we would use an encoder and each time we received a new or additional diagnosis we would have to start over. Now, new information is simply added to the list, which saves a tremendous amount of time.”
Chartwise was this hospital’s choice, and they are happy with the choice. That is not to say other vendors don’t also have good products. Rather, the lesson here is that ICD-10 can be done well and painlessly.
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