Administrative FAQs

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To optimize reimbursement by improving the accuracy and speed of the documentation process and reducing the associated financial risks, waste, and inefficiencies.

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ChartWise:CDI was developed by a physician, Dr. Jon Elion, to help other doctors, hospitals and Clinical Documentation Specialists improve the accuracy of documentation. He recognized that, since tracking of diagnosis is dependent on the doctor’s notes, it makes sense to start the process by helping doctors translate their clinical language into diagnostic terms accepted by Medicare and other payers. This streamlines the previously cumbersome communication between CDS and doctor, and provides more security in creating proper DRGs.

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The hospital gets several benefits, primarily in ROI on Medicare patients. In addition to optimizing DRG information upfront, it lowers its risk of Medicare paybacks due to RAC audits. It also has an audit trail of all communication between doctors and CDS staff, so you can track query response rates. In a more global view, it enables you to gather and use statistics related to Case Mix Index, resource utilization and medical error identification, among other metrics. In short, ChartWise:CDI helps the CEO improve efficiency, the CFO improve reimbursement, the CMO access performance metrics, the medical professionals use their time better, the coding/billing staff enhance accuracy of DRGs, and the CIO take a rest due to its ease of installation and use.

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ChartWise:CDI requires a short hard-dollar ROI and little to no capital outlay.

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Over 51% of Medicare paybacks are due to erroneous or incomplete documentation. In an initial study of just five states, Medicare recovered over $900 million in overpayments. And now that all hospitals will be audited by Recovery Audit Contractors (RACs) employed by Medicare, the danger of mandated repayments has increased exponentially. Medicare has also incentivized the RACs by offering them a percentage of recovered monies.

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It’s been estimated that a 250-bed hospital experienced over $500,000 in lost revenues in 2009, just due to inadequate documentation.

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Partly because doctors typically use clinical terms rather than the diagnostic terms preferred by payers. Under previous Medicare payment systems, hospitals typically were reimbursed approximately $5,000 for a patient with a primary diagnosis of “Congestive Heart Failure” (CHF). Under the new MS-DRG program, that reimbursement has fallen to $3,500. However, if diagnostic clarifications are provided, such as “Acute Systolic” or “Acute-on-Chronic” CHF, reimbursement increases to $7,000. Complications and co-morbidities make the situation more difficult. In one particular hospital if a patient undergoes major bowel surgery, and also suffers from CHF, the reimbursement is $11,178. But if terms such as “Acute Systolic” or “Acute-on-Chronic” are entered, reimbursement increases to $36,015. The increase is based on the addition of just a few words, but the terms “Acute Systolic Heart Failure” or “Acute-on-Chronic Systolic Heart Failure” are not terms in common clinical use. If a doctor does not enter these words, the hospital suffers the consequences. ChartWise:CDI helps the doctor fill in those blanks.

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It is unique in several ways, the primary one being that it is the first and the best Computer-Assisted Clinical Documentation (CACDI) system on the market. It was built on the physician’t input to acquire and verify the best data. Designed by a doctor, it offers medical professionals the comfort they need in entering information, and the help they appreciate in providing the right language for payers. ChartWise:CDI helps organize the documentation workflow so that everyone’s time is spent efficiently and wisely. It also incorporates a rules based expert system that interacts with physicians and customizes itself as data is entered: it “learns” from patterns in your hospital. ChartWise Medical Systems is an unusual enterprise that brings together experts who combine the required knowledge and skills in clinical medicine, medical informatics, computer systems design and artificial intelligence.

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For the best answer, view the demo on this site. In brief, ChartWise:CDI starts with the medical professional entering data on a patient’s condition and treatment. This can be done on the easiest platform for your situation: laptop, desktop, etc. When a clinical term is entered, the program provides drop-down menus to ensure translation into the proper diagnostic term or terms used for reimbursement. This information is accessed by your CDS or coding/billing staff, who can then submit queries to the doctor for clarification.

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There are several workflows that can be supported by the system, including the situation where the physicians are reluctant to interact with a new computer program. Where only the CDS staff is using the system, there are still major benefits in revenue enhancement, query management, improved efficiencies, audit support and metrics. Training new CDS’s is especially facilitated, as they can be guided by the expert system to bring to light additional diagnoses based on lab value abnormalities or medications. The DRG Review capability shows the potential impact of new documentation, and can guide the proper query selection. Hospitalists are favorably disposed to use the system as they are often evaluated on their documentation practices. ChartWise:CDI allows them to document conformance and cooperation with the CDS queries. Reduced time and increased precision of charting that results from responding to queries electronically has proved popular. And of course, physician participation in all aspects of the EMR will be required in the near future as we move ever-closer to the paperless chart.

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Taking care of your patient population is the whole point. Freeing up the doctors’ time for patient care. Helping to secure cash flow to provide better services. Giving you information about such important facts as comparative length of stay. The more you optimize reimbursement, workflow, efficiency and procedural oversight, the more you can improve the delivery of medical services.

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This was a consideration from the very start of development, and the capability to handle this change is built in. Our knowledge-based expert system can easily manage the transition, which is an important factor, since the changeover is anticipated to incur major costs and considerable chaos for hospitals and medical information system vendors.

Medical FAQs

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 It was created by Dr. Jon Elion, a physician who understands the pressures on a doctor’s time. Other medical professionals consulted on the development as well. By putting the physician at the forfront of the process, ChartWise2.0 cuts down the total time spent on documentation.

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The doctor enters clinical terms that describe the patient’s condition and the treatment delivered, and the program suggests diagnostic terms that satisfy the requirements of payers. By helping to define and refine this description at the outset, ChartWise:CDI cuts down on the later back-and-forth queries that normally interfere with a doctor’s day.

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Similarly, the first pass of information the CDS gets is more clinically accurate and detailed than it would be from the usual chart entry. Result: fewer sticky notes, phone calls and e-mails, as well as more accurate information provided to your coding/billing department.

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The staff completes its documentation work faster and with greater precision. The physician spends less time on paperwork and more with patients. The CDS has fewer questions to ask, and doesn’t have to decipher handwriting.

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No. It encourages greater specificity with respect to terms required by Medicare and other payers, but does not “prompt” the user to up-code. The electronic queries fully conform to the query guidelines from the American Health Information Management Association (AHIMA).

Technology FAQs

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Dr. Jon Elion, creator of ChartWise:CDI, previously founded Heartlab, which was the world’s leading designer of cardiology digital imaging and information networks. He understands the need for flexibility and simplicity. ChartWise:CDI’s core technology is a rules-based expert system for codified medical information, with a focus on healthcare informatics. This is enhanced by applying a medical taxonomy on top of the coding, giving the program a medical feel comfortable for doctors.

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It combines facts entered by the doctor with an encyclopedic set of information about lab tests, clinical diagnoses and the medical terminology preferred by payers, and generates suggestions for the physician to review and correct or confirm. This makes the provision of accurate codes, documents and DRG terms smoother and optimal.

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Very easy; there is nothing to install. ChartWise:CDI is a web-deployed program that is hosted on your application server. It doesn’t require Java® or .net. A web browser is all that is needed to access the system.

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This was another primary consideration. Its intuitive interface requires very little training for users.

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Users will access the system via a standard Internet browser.

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Our servers are hosted by Peer 1, one of the largest and most respected Tier IV data centers in the US. Utilizing military-grade physical and electronic security, they claim 100% up time.

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Yes. In addition to the security provided by our hosting partner, Peer 1, all patient identifiable data is encrypted within the database and can be viewed only from within the software application. Further, web pages are never cached on the user’s browser.

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A minimal amount. A site administrator assigned by the hospital, such as a Clinical Documentation Specialist, would manage the hospital’s user access. Because the program is hosted on our servers, there is no software for the IT department to install or maintain.

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Customers are fully supported throughout their contract, with a technical support team available 24/7. ChartWise also provides setup and installation services and workflow consultation.

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Because the application is hosted on the web, updating is automatic for users. The rules system and user interface can be modified quickly. The capability for multiple languages and diagnostic coding schemes has been built in from the beginning.

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Rules-based expert systems have been around since the early 1970′s, providing expert-level solutions to important problems. In the case of ChartWise:CDI, there are currently over 30,000 rules in its knowledge base that provide insight into precise medical nomenclature, diagnostic terminology, laboratory test results and medications. These rules are combined with facts provided by the user to draw pertinent conclusions. An extremely simple example of this would be where the user inputs information about a patient with Congestive Heart Failure (CHF). The rules expert would then suggest further clarification on the nature of the CHF “systolic”, and its onset such as “acute”. These facts are then combined by the rules engine into the single ICD9 code 428.21 (“Acute systolic heart failure”). Expert Systems have a strong advantage over traditional computer programming methods for problems (like Clinical Documentation) that involve significant “branching” and decision-making, with rules that will evolve over time, and where it is helpful to separate the “business logic” from the rest of the system.

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Historically, the use of Expert Systems in medicine has been hampered by difficulties in developing and maintaining the medical content. Traditionally, because of the complex coding required, the “medical domain expert” usually a physician, needs to work side-by-side with a technical expert, usually the programmer, to develop rules. We have developed an innovative medical content authoring system that can be used directly by domain expert. This frees the author to think medically, and not have to deal with the underlying programming syntax.

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We have a very senior development team, averaging 25 years of computer engineering experience! We use a process known as “Agile Software Development”, which is a group of software development methodologies where requirements and solutions are created and managed through collaboration. The methodology promotes disciplined project management with a set of engineering best practices that allows for rapid delivery of high-quality software. We have extended this to include “Agile Testing” as well, and have built sophisticated automated testing procedures into our development process. This means that even the smallest change to the medical content or to the associated software can very rapidly be put through rigorous and exhaustive testing, assuring the highest quality finished product.

Glossary FAQs

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