Remote CDI
Currently in our program, our inpatient CDI nurses work from home one day per week, mainly due to our hybrid medical record. However, the use of electronic progress notes is increasing every day. We currently email our queries to providers often, but would like some feedback as to how remote CDI gets their queries to their providers and what the response rates are. Our response rate is right around 90% but use several venues for communicating our queries (verbal, email, leave in mailbox, leave in hard copy chart, leave on physician desk.) My director would like some feedback from other facilities on the success of their remote positions in regards to common metrics.
Comments
I have managed a 100% 'remote' CDI program since 2011. We are located at our corporate office and not onsite at the hospitals. Our medical group and hospitals all share the same EMR so it is easy to view records across the spectrum. That said, as our program progressed in responsibilities from traditional CC/MCC/CMI type queries into Quality reviews (Mortality, PSI, HAC's, etc) and Clinical Validation queries - the 100% offsite relationship no longer works, in my opinion. The discussion of these advanced CDI topics is too complex to be adequately addressed via written messaging. What I feel is missing from a remote program is face to face conversations, rounding with physicians, or even just being available on nursing units or an in-hospital office to field physician questions or to discuss cases in a spontaneous and fluid dialogue. A written message is not a discussion; a conversation is. Our physicians have no personal relationship nor connection to us. We are an electronic message - that's all they see of us. We waste tremendous time trying to have our points be heard electronically. Asking physicians to call us is an additional step - a barrier. Our written messages are often put aside for more pressing priorities. If we were present onsite, I hope we could more conducively meet the needs of both our CDI team and support our physicians better. Our organization has set the expectation in the past that everyone has to respond to queries (provider may or may not agree with the suggestions - but need to respond in writing or verbally to the CDI team)... but because of our offsite nature some of the queries drag on up to a month. I do not recommend 100% offsite CDI and have been exploring options with our executive team here for a model that is more effective. Feel free to call or e-mail me direct with more questions.
Tricia McGinn, RN
847-982-4212
tmcginn@northshore.org
Tricia,
I am glad that you responded to this question since you have a 100% remote program. We are not remote and several of my CDSs have been requesting to go remote or to work a few days a week from home. I am against this practice for the reasons you cited. I just don't think it would work without interaction with the providers. Do we all want to work from home? (most of us, yes.) It is feasible? I don't think so in these times of VBP with so many evolving quality related measures. There's nothing like looking a provider in the eye to have that conversation with or to smile, nod and speak knowing he/she is about to open a record where you just placed a query for them. In my experience, our providers usually answer right then and there if you are looking at them. Out of site, out of mind is my thought on the subject.
Thanks for sharing so candidly.
April Floyd, RN, CCDS
afloyd@andersonregional.org
I manage a blended team with some onsite staff and some remote. We have 7 sites spread across tremendous geographic distance and we work in a very high cost area. A blended team provides advantages of onsite and remote. The remote workers are tremendous productive in terms of meeting all expectations. All of our communications are sent via EPIC and we have devised very effective and evidence-based query forms that are easy to read and facilitate MD response...our response rate is over 90%. We provide a multitude of education via strategic face-to-face communications, seminars, and documentation tips. With the advent of the electronic record, our staff are not as available to CDS when compared to the paper environment and staff complete records OFF the floor, at home, in a break area.....which is a benefit the physicians expect to accrue to them with the electronic record.
Paul Evans, RHIA, CCDS, CCS, CCS-P
In agreement with Paul, remote CDI programs can be successful with help of systems placed to achieve this goal. We are 100% remote and also use EPIC with a designed "pop-up" query process that is activated and later de-activated by the CDIS when the query has been addressed in the record. This query process was agreed upon along with physician leadership and creates much higher productivity rate for the CDI team and less interruption to the physician at less than optimal times of day. The theory was based around that a query will "pop up" in the EMR when the that particular patient record is accessed by the physician thus prompting real time query response. If questions need to be clarified with the CDIS, our contact information is located within the query. Our response rate is also over 90%. Lack of floor conversations can be supported/supplemented by a good physician education plan, and the CDI Manager/team do periodically meet onsite for staff meetings/goal setting/educational forums etc. Otherwise...we are doing well as a remote program and have successfully formed respectful working relationships with the physicians along the way, including from the remote office environment. If you have any further questions, please feel free to contact me.
Lara Faustino RN BSN CCDS
Clinical Documentation SpecialistBoston Medical Center
617-414-7787
lara.faustino@bmc.org
Regarding floor conversations, in my experience, our physicians might occasionally allow for a very, very brief conversation with CDS, but in reality, the physicians are dealing with patients, Discharge Planners, Social Workers, and the other multitude of professionals that must have interaction with them in order to properly care for the patient, I am not delegating CDS to 2nd class status, but the reality is that such conversations with them are happenstance. When we went with EPIC, we found staff even less available on the units as they do not want to chart on the floor.
A well-crafted and written query should contain context, clinical support and compliant responses such that it stands on its own merits. Again, not negating the value of interactions, but we schedule our interactions. Plus, factor into the equation the challenges one has staffing qualified CDS in urban and high cost areas whilst we have qualified CDI that may be looking for remote work - Remote makes total sense to me and I think it will be more and more utilized in some programs.
Paul
Hi Val,
We work entirely in a remote environment using Meditech. I've also worked as a CDI consultant in the Epic environment. In both cases we used an interdisciplinary progress note type of query that the physician must answer and co-sign. In my current role, we work very closely with the UR nurses as they often are watching length of stay and do occasionally round with the Hospitalists. We share any concerns regarding documentation by providers who perhaps aren't entirely responsive via the CDI champion and Quality team. Marie
Paul,
Would you be willing to share your address so I could contact you directly about this? What is your hospital system?
Thanks
Deb
I'd just like to say, It really doesn't matter whether we're working as a floor CDS or a remote CDS. The point that matters is if the Physicians have become a vital link to our concept and a valued partner in the product we deliver on a daily basis. For without their active daily participation and acceptance of our queries and their willingness to participate with documentation excellence, it doesn't really matter what chair we sit in or where we're located.
I've worked both as a hospital based CDS and a remote based CDS. I've seen both sides work well, and occasionally...not so well. Participating Physicians are the major key factor, no matter how you try to slice this pie.
Diane Moore, RN MPA CCDS
Deb: Of course:
415.412.9421
evanspx@sutterhealth.org
Paul,
That is so true and thank you for sharing! Is it okay to contact you for more detail information? Thanks!
Shun No Chan, RN, BSN, CCDS, CCM, CCS
Clinical Documentation Imrpovement Coordinator
Yes - feel free to contact me.
415.412.9421
At Wellstar, we use the interdisciplinary notes, at least from Dietary as pertains to malnutrition, as codeable documentation when the MD cosigns the note. In EPIC, the dietician flags the chart for MD to cosign her note and then it gets coded and no query is necessary, as long as MD has noted in his documentation that he is treating it, whether or not he states the diagnosis itself. Same with Wound Care notes.
Kathryn Conlon, RN, CCDS
Wellstar Healthcare System, Atlanta GA
Kathryn.conlon@wellstar.org
Jennifer Bailey, RN, CCDS
jbailey2@carilionclinic.org
540-739-5990