EMR - Cerner

kelley.huff@wjmc.orgkelley.huff@wjmc.org
in CDI Talk Archive
I was wondering if there are any CDS programs using Cerner for thier EMR and if so what are the advantages/disadvantages? How are you sending electronic queries or are you still using paper queries? We are in the planning stage of our transition to a total EMR using Cerner but just heard that the physicians have decided the only requests they want sent to thier inbox are deficiencies from HIM. That would prevent us from sending electronic queries. We are concerned that if we continue to use paper queries and the docs are using the EMR - they will not be looking at the queries on a scaled down paper chart. Any insight as to how your facilty handles this or general feeling about using Cerner is appreciated. Thanks. Kelley

Comments

  • sbeattysbeatty
    edited May 2016
    I consider a query to clarify the documentation in the chart to be a
    deficiency. Work with your HI department to get a deficiency assigned.

  • tdavistdavis
    We currently are using Cerner for the majority of our record. We do still have a paper record for physician progress notes and OR procedures. We currently place a paper copy in the record and then we scan the query at the same time into a queue to be place in the medical record as a scanned document under the administrative folder. If you have any questions, please feel free to contact me.
    Theresa Davis RN, BSN, CCDS
    Clinical Documentation Specialist
    tdavis@emh.org
    Phone: (207) 973-5178
    Pager (207)818-0348
  • catladyrncatladyrn
    We are 100% EMR, using Cerner. We have no paper chart to place a query and we have no mechanism to guarantee that the physician will open their Cerner email, and TPTB have dictated no sticky notes, so we have a lot of unanswered queries. The system has only been in place since June--many issues to resolve. But I don't know of any physicians who have actually balked at receiving the emails.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • stacy.vaughnstacy.vaughn
    edited May 2016

    We use cerner, but we are not 100% paperless. We still use paper queries
    and get a great response.

    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052



  • dvitalone1dvitalone1
    edited May 2016
    Where are you placing the queries? Are your progress notes paperless?

    DAWN M. VITALONE, RN
    Clinical Documentation Improvement Specialist
    Community Hospital
    Munster, IN 46321
    (219) 513-2611

  • lspryszaklspryszak
    I agree with others that unanswered queries should be considered a chart deficiency. Of course this will cause an outcry from some providers, but there has to be strong administrative support for your program, and this is an excellent of example of how administration can support your efforts by approving the process that includes unanswered queries as chart deficiencies.

    Something to perhaps to support this suggestion to administration:

    Many queries are generated so that the assigned codes can withstand audits (be clinically supported) from the RACs, the OIG, the CERT program, the MAC, and third-party payers. Queries do not only generate revenue on the front end, they can prevent denials of claims on the back end. One case in point, excisional debridements, a HUGE RAC target. Without excellent documentation a facility stands to lose hundreds of thousands of dollars on poorly documented cases coded to 86.22. Without the proper documentation (usually through CDI efforts), those surgical procedure codes are "downgraded" to 86.28, which can often downgrade the MS-DRG from surgical to medical -- and we all know how that 86.22 code can impact the DRG.

    Another example that we will all face come October 1st is Acute Renal Failure. Same situation, different code.
  • stacy.vaughnstacy.vaughn
    edited May 2016

    We are placing the queries in the progres notes section on the chart. We
    still have paper progress notes.

    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052



  • davisd2davisd2
    Hi Theresa,
    I was just curious, we are going to be completely EMR soon with Cerner. You stated that your queries are scanned and are a part of the medical record? Our queries get pulled before scanning. Just wondering why yours might be a part of the record.
    Denise

    Denise Davis RN
    Clinical Documentation Specialist
    Quality Management
    Sonora Regional Medical Center
    1000 Greenley Rd Sonora Ca 95370
    209-536-3290
    davisd2@ah.org
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