My practice setting is clinical documentation improvement (CDI). The CDI nurses review the clinical record for completeness and clarification of the documentation. It impacts financial reimbursement based on coding, but also patient safety indicators and, hospital-acquired infections, and readmissions. Providers must document if a diagnosis is present on admission (POA) to avoid a chronic diagnosis from being seen as a complication after surgery or for an infection that the patient had on arrival. The CDI nurse queries the provider to ask for clarification of documentation based on clinical indicators. Or to identify if a diagnosis was POA. In the past, the query was not a part of the medical record, and the provider had to find the previous progress note and make an addendum (Arrowood et al., 2015). I have been designing and leading a HIT initiative to have the CDI query to be a progress note type. The provider will receive the query in his/her Inbox and will edit the progress note query with his/her responses and then cosign the CDI query progress note. It then becomes a part of the legal medical record and is transparent for all providers to see the information. The implementation begins on August 1st with the education of the providers at the first hospital. The rationale for this change is to create an easier response method for the providers, to decrease the time for the provider to respond, and to provide transparency and clarification in the legal medical record.
The biggest barrier to the HIT initiative was working with the information technology (IT) team to complete the configuration. IT did not understand the workflow, and several design sessions took place to create the right workflow. It extended the time of the implementation by four months. To implement this change, the Technology Acceptance Model (TAM) was used to influence the change. The TAM states that if the users believe that the HIT will useful and easy to use, the users will be positively influenced to accept the new change (Pai & Huang, 2011). For the past five months, I have been meeting with the hospital steering committees, internal medicine providers, finance, quality, and population health to promote the change and how it will improve the documentation that affects their departments. It has created excitement within the healthcare system and the anticipation of using the new process.
Leaders understand the roles of each member of the interprofessional team and work with them for a successful implementation. They work towards implementing systems based on evidence-based practice (Graduate-level QSEN competencies: Knowledge, skills and attitudes, 2012). The queries are based on guidelines from the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS) and the Association for Clinical Documentation Improvement Specialists (ACDIS). TIGER leaders will use a champion approach to implement change (Walker, 2011). To make this change, I worked with our chief medical information officer (CMIO) to create the education for the providers using Brain Shark. Dr. Budman, the CMIO, reviewed the education and recorded the eLearning to send to the providers. The physician advisors for CDI at each hospital have been trained as super users and will reinforce the training and use of the new queries.
Although I am not currently working in the nursing informatics area at my healthcare system, I have been able to use my informatics competencies to influence this important change in my healthcare system. Don Marker (2010) states, “The leader is great at explaining why something needs to be accomplished and then empowers those responsible to get it done” (Marker, 2010, p.32). I was able to empower my CDI team to assist in the education of all providers, and they will be teaching and reinforcing the education from the eLearning to the providers in provider lounges and specialty meetings. The communication of the ease of use, usefulness, and education is creating a culture of willingness to change.
Arrowood, D., Bailey-Woods, L., Easterling, S., Endicott, M., Love, T., McDonald, L.,Wieczorek, M. (2015). Best Practices in the Art and Science of Clinical Documentation Improvement. Journal Of AHIMA / American Health Information Management Association, 86(7), 46-50.
Graduate-level QSEN competencies: Knowledge, skills, and attitudes.
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