Problem List–Centric CDI Workflow: Better Care Through Communication in the Age of the Electronic Medical Record
Sheilah Snyder, MD, FAAP
Physician Champion CDI, Pediatric Hospitalist
Marietta Morhardt, BSN, RN, CPN, CCM
CDI Specialist
Children’s Hospital & Medical Center, Omaha, NE 1
Learning Objectives
• At the completion of this educational activity, the learner will be able to:
– Identify benefits and disadvantages of various EMR‐based CDI workflows
– Describe the workflow of using BestPractice Advisories (BPAs) as a communication tool for a CDI program clarification
– Assess the goals and metrics of a successful pediatric CDI program
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Children’s Hospital & Medical Center •
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Smallest town in U.S. with 2 med schools
145 beds
Total patient visits in 2015: 450,000
Inpatient admissions: 8,200
Specialty clinic visits: 94,000
General pediatric clinic visits: 210,700
Children served in pediatric clinics: 88,400
Emergency & UC visits: 48,300
Critical care transports: 1886
Surgery cases: 12,400
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Provider Communication CDI Clarifications
• Traditional methods have not been terribly successful
– Epic EMR
• Sticky notes
• Inbasket messages
• CDI specific note type
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Sticky Notes
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Inbasket Message
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Inbasket Message
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Provider BestPractice Advisory (BPA)
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Provider Communication
• Why BestPractice Advisories (BPAs)?
– Implementation of EMR automation to help improve CDI process
• BPA is an alert that can be addressed when the provider opens the chart
• Problem list–based note templates
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Provider Communication • BestPractice Advisory CDI Clarification—CDI RN review of all inpatient charts, re‐review weekly, follow up on all clarifications
• Daily in‐person attendance at rounds by CDI RN for live feedback, with subsequent documentation in EMR for tracking purposes
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Building a BPA
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Building a BPA
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
CDI Clarification From BPA to Note
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Provider’s View BPA
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Problem List—Browse Common Diagnoses
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Problem List—Preference List
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Problem List—Database Lookup
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Progress Note Template
• APSO format for all notes
• Problem list–based assessment
• Still requires the provider to address each problem in the plan, which is free text entry
• Note can be “copy forwarded” for next day but needs to be updated
• Problem list is updated every day in rounds
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Progress Note Template
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Progress Note Template
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BPA Provider Workflow
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
BPA Provider Workflow
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BPA Format
Advantages
• High response rate
• Quick response time
• Utilizes problem list–centric note templates
• Standardization of documentation format
• Able to quickly gain data from verbal interactions during rounds
Disadvantages
• CDI clarification directs provider to update the problem list that flows into the note template. This is simply a reminder to the provider that they still need to address this problem in their plan. 23
CDI Nursing Review Process
1. Review queue that includes patients admitted 24–48 hrs prior (inpatient only—not reviewing observation at this time)
2. Round daily with providers on a rotating schedule
3. Send out BPA clarifications as needed
4. Follow up on previous day’s clarifications/may call or email if no change or response
5. Educate as needed and opportunities arise
6. Will refer providers to physician champion if repeated lack of response to clarifications sent
7. Meet regularly with physician champion to review any issues with process or clarifications
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Top CDI Clarifications at Children’s
18%
3%
Intellectual Disability 28%
28%
Acute Resp Failure 9%
12%
Chronic Resp Failure 3%
9%
Malnutrition type 27%
Obesity 12%
27%
Anemia type 3%
3%
Other 18%
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2015 CDI BPA Results
• 652 BPAs sent
• Response to BPA questions in EPIC: – Accept: 348 (53%)
– Disagree: 26 (4%)
– No response: 278 (43%)
• BPA questions not always answered, but usually the changes are made in the problem list and documented in the notes • Goal “agreement” with clarification: 80%, which means they made the documentation changes
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National CMI Data From PHIS
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Omaha Children’s Case‐Mix Index
1.6
1.5
1.4
1.3
1.2
1.1
1
2009
2010
2011
2012
2013
2014
Source: PHIS
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Financial Impact of CDI on CMI
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Next Steps
• Standardization of note templates
• Data review for additional documentation improvement opportunities
• Reviewing observation patients, outpatients
• Educational opportunities: new providers, midlevels, new residents
• CDI reconciler bridging the HIM/CDI relationship
• Pediatric definitions that are widely accepted nationally: Acute resp failure
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©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Thank you. Questions?
shsnyder@childrensomaha.org
mmorhardt@childrensomaha.org
In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 31
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.