Is the introduction of New Information on a query really inapproptriate?

hooter1964

“The introduction of new information not previously documented in the medical record is inappropriate in a provider query.”
I struggle with this concept after the United States Government CMS put out these Goals for meaningful use:
“The goal of meaningful use is to promote the spread of electronic health records to improve health care in the United States.”
The benefits of the meaningful use of EHR include:
• Complete and accurate information. With electronic health records, providers have the information they need to provide the best possible care. Providers will know more about their patients and their health history before they walk into the examination room.
• Better access to information. Electronic health records facilitate greater access to the information providers need to diagnose health problems earlier and improve the health outcomes of their patients. Electronic health records also allow information to be shared more easily among doctors' offices, hospitals, and across health systems, leading to better coordination of care.

Source: www.healthit.gov/policy-researchers-implementers/meaningful-use
So I ask all you AHIMA and ACDIS policy makers this:
Is it wrong to use Recent Diagnostic Studies ie Labs, Echo’s, Imaging etc available on a Hospital’s EMR whether it is from a office visit, clinic visit or Outside Hospital whenever there is conflicting, ambiguous, or incomplete information in the current health record regarding any significant reportable condition or procedure?
To me that AHIMA brief statement is like withholding insulin in a diabetic until they reach the point of DKA.

sharon.cooper@owensborohealth.org

My humble two cents worth: I know you can use the most recent Echo results (even if from prior admission/encounter) when querying for CHF specificity, but that is the only thing from previous admissions or encounters that we use in our queries.

Sharon

Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals/MDS/PPS

Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007

sharon.cooper@owensborohealth.org
(270) 417-4612 Office
(270) 316-9088 Cell
(270) 417-4609 Fax

katysuegood@gmail.com

While I understand your point, I think we also have to think about these issues from a resource-utilization standpoint. If a diagnosis is going meet criteria to be coded, there should be significant evidence of that diagnosis in the medical record from which a query can be built. While being able to bring in a dx from a prior admission (like malnutrition or CHF) may be tempting, in order for it to meet criteria as a secondary dx, there should be evidence of this dx (signs/symptoms/labs/treatment). If not, it didn’t impact care. You may be able to provide some examples of where this is not true but in general, I think it applies.

It seems like if we could bring in all data from prior encounters, there would be need for constant scrutiny as to whether this diagnosis impacted care on THIS admission and thereby meets criteria for inclusion on the coding summery.

The reality is that when we are talking about easy transfer of information between providers/facilities we are really talking about providing the best quality care to our patients. This is somewhat different than looking at those records in an effort to capture an many dx as possible and ultimately impact SOI/ROM, reimbursement, etc.

When it comes down to it, all dx need to be relevant to THIS admission. If there are not enough clinical indicators in the current record to support a query, it likely shouldn’t be included on the coding summery anyways.


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

sharon.cooper@owensborohealth.org

I agree with Katy. We use the most recent Echo if querying for specificity of clinically significant CHF.

Sharon
Q&A: Querying for CHF using prior documentation
CDI Strategies, January 8, 2009

Question: Part of our clinical support for determining the presence of congestive heart failure (CHF) includes referring to an echocardiogram performed during a previous admission. Using our electronic record, the physicians can access this same information to review it for mention of systolic or diastolic dysfunction in order to provide a link to exacerbation of CHF. Would using this prior documentation be considered "illegal" under the new American Health Information Management Association (AHIMA) final physician query practice brief?

Answer: I do not believe it would be illegal for query the physician for clinical information that is present in the old record so long as there are clinical indications and/or documentation supporting that the condition qualifies as a principal or additional diagnosis. Specifically regarding CHF, it would not be wrong if a physician documents that a patient has CHF and a query discusses a previously performed echocardiogram. The question could be posed as follows:

Dear Dr. Jones,

Your progress note of XXXX date confirms that this patient has CHF. On XXXX date, the patient had an echocardiogram that was interpreted as having left ventricular dysfunction, impaired ventricular relaxation, and an estimated ejection of 45%. Please comment upon the nature and acuity of this patient’s CHF. Options may include:

Nature Acuity
Systolic Chronic alone
Diastolic Acute or acutely decompensated alone
Both systolic and diastolic Acute on chronic
Other: Other:
Cannot be determined Cannot be determined

Please also indicate the underlying cause of the patient’s CHF and any other condition that affected its stability during this hospitalization.

(James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question.)






Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation

Owensboro Health
P.O. Box 20007
Owensboro, KY 42304

Sharon.cooper@owensborohealth.org
Office: (270) 417-4612
Cell: (270) 316-9088
Fax: (270) 417-4609

dallend@einstein.edu

We do not use information from MD visits. clinic visits, etc. when
querying. The basis for a query, to the best of my knowledge, should
only be the information in the current hospital record (you are
querying) - meaning information documented by physicians caring for the
patient this admission and documented in progress notes, consults, etc.

We have alway had information from other providers as part of our paper
medical record. We will have the nursing home records, MD outpatient
office records, etc We have never used that information in a query. We
read it but we do not query based on that information.

I will be interested in what other have to say regarding this.

Debby Dallen,RN
Albert Einstein Medical Center
Phila PA 19141
dallend@einstein.edu

angelisa.romanello

I agree with all the information below, however there is one very important point in our facilities.
We have a hospitalist group which rotates through both campuses. If a patient presents for another admission, the previous documentation in the electronic medical record can be helpful in providing accurate or quality care for this admission.

I strongly caution my CDI team to only use current information for queries or diagnosis retrieval.

I do believe the EHR can be a valuable tool for the provider and then we can obtain our information from their accurate presentation of the patient's current condition.


Lisa Romanello,RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
CJW Medical Center
Quality and Compliance
804-228-6527

sbeatty

Amen Katy. At the end of the day the medical record needs to accurately reflect the severity of illness, the care provided and the outcomes achieved/plan of care going forward during the current admission. The rest will take care of itself.

sbeatty

If a patient has a history of chronic HF and is admitted with that as an acute unspecified problem, would you as a CDS look up the last echo and note the findings, making sure to reference that this data is from XXX date? To me, that is relevant and is a service to the MD, which adds value to our work to improve documentation. It has historically been a service my MDs appreciated and it takes so little of my time and helps with their work flow. Our work is all about being perceived as a collaborative presence and relationship-building is key to success.

sbeatty

Thanks, Sharon. I rest my case!!

dallend@einstein.edu

We are not permitted to use ECHO results that were not performed during
the current admission unless the provider refers to the testing in the
H&P or progress notes of the current admission.
Our practice is the current admission must speak for itself.




Deborah A Dallen,RN, CCDS
Albert Einstein Medical Center
Phila PA 19141
Clinical Documentation Coordinator
Health Information Management
215-456-8902