CDI Software

nbrunson84

Do you currenly use CDI Software?

If Yes - do you feel it meets the needs of your program?

Do you utilize all the reports and statistical information?

If No - how do you currently keep your information? Queries?

Would you be interested in software if it made your work easier?

(I am NOT a software rep...just interested in how many programs are automated.)

digardsk

Yes - yes - for the most part.

Kim

Kim Digardi, RN
Clinical Documentation Specialist
St. Helena Hospital
10 Woodland Road
St. Helena, CA 94574

Phone: 707.967.5936
Email: digardsk@ah.org

robert.hodges2

I don't use CDI software. I built my own database in Access to track my work.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"To climb a steep hill requires a slow pace at first."  -William Shakespeare

dbutler

Yes (consultant software as well as a Morrisey product for work lists and organization within the live system)

No -- the consultant software does not do data analysis the way my brain works, so I do my own within MS Access, though the consultant software does capture raw data for me)

Yes -- cost and customization are large issues -- reality, not likely to be able to get anything new. Want to expand what current software (Morrisey) captures for me but IS is overtaxed with an EMR.

Don

fishdl@shands.ufl.edu

We enter our reviews, queries, responses, etc. in Softmed from which our IS Analysts have created reports and worklists to help automate our tracking and reporting. It's great when it's working properly, but it requires quite a bit of maintenance.

cbarnes

yes we use it no it does not meet our needs

susanklein

Yes, we have software. It does not meet all of our needs.

Susan A. Klein, BSN, RN, C-CDI
Saint Peter's University Hospital
Director, Clinical Documentation Mgt
office: 732-339-7613
fax: 732-745-5944 (specify room B175)
pager: 732-651-4359

dallend@einstein.edu

We enter our data in Soft Med - No it does not meet the full needs of our program. IS programmed some reports and I put together some reports. We have used 3M software, JoRo - they didn't meet our needs and the data was not accurate. We looked at Navigant and one other vendor (I can't remember the name) - didn't like them.

dog

Yes, we use software that our corporate office requires us to use. I think it's a good program for a brand new CDS, but severely hampers my efficacy as my experience grows. I'd like something that doesn't force me to ask "yes" or "no" questions and that doesn't penalize me for a "no." The whole focus is on revenue, not compliance. Sometimes I need to ask a query that actually lowers our reimbursement but is a more accurate reflection of the patient and the care and will keep us out of trouble with the regulators.

Linda Renee Brown, RN, CCRN
Clinical Documentation Specialist
Arizona Heart Hospital

dbutler

I would be EXTREMELY concerned about something that forces yes/no questions -- sounds like it is a compliance violation. Has your corporate compliance signed off on these queries? (since the software comes from the corporate office).....take a look at the AHIMA practice brief on the ACDIS helpful resources page... or try this direct link:

http://library.ahima.org/xpedio/idcplg?IdcService=GET_HIGHLIGHT_INFO&amp;QueryText=xPublishSite+<substring>+`BoK`+<AND>+(xSource+<substring>+`AHIMA+Practice+Brief`+<NOT>+xSource+<substring>+`AHIMA+Practice+Brief+attachment`)&amp;SortField=xPubDate&amp;SortOrder=Desc&amp;dDocName=bok1_040394&amp;HighlightType=HtmlHighlight&amp;dWebExtension=hcsp

Don

dog

I don't think I was very clear about what I meant by yes/no. What I meant is that I have to ask something like, "Are you treating acute systolic heart failure? If you concur, please document, etc." I then must track for statistical purposes whether they say yes or no to my direct question. I would prefer the option of asking open ended questions such as "based on ....would you please clarify whether you believe this is an acute, chronic, or acute on chronic problem" or "can you please clarify what you suspect to be the cause of the syncope."

If I ask a question like, "You stated possible pancreatitis in your H/P but it has not been addressed. Based on .... do you still consider it a diagnosis?" and they say no, then I get a "denied" on my query and I look bad, instead of good for having clarified confusion in the chart. I don't get to ask, "based on...could you please clarify if it remains an active problem or if it has been ruled out." I also don't have a mechanism for clarifying discrepancies between physicians. Dr X says USA but Dr. Y says NSTEMI. I have to choose one of the possible diagnoses, ask if it's the right one, and when they tell me which one, if I picked the wrong one, I get a "denied" again. I would rather ask, "Dr. X says USA but Dr Y says NSTEMI...based on .... could you please clarify the current active diagnosis."

I just hate our software and our tracking systems. I think I could do better.

sbeatty

Forget the software and be compliant with your queries. This morning I
received a newsletter that RAC Connolly Consulting is asking not for
medical records but for "clinical documentation." Specifically, if I'm
reading this right, they want copies of queries and physician responses
to queries. While your first example may allow you to have accurate
data, I would consider that to be a leading query.


Pressing RAC Issues Get Ironed Out
by Chuck Buck and Dennis Jones

Read more... <
http://www.racmonitor.com/news/33-top-stories/301-pressing-rac-issues-ge
t-ironed-out.html>



Is there anything else I can do for you?
Clinical Quality Management would like your feedback on our ability to
meet your needs. Please complete a satisfaction survey for our
department.

Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org

"The most important thing in communication is to hear what isn't being
said." Peter F. Drucker

dbutler

In the cover letter regarding our lot of almost 90 charts recently submitted to Connolly, they specifically identified physician queries to be included with the medical record.

They obviously are looking at queries to some degree!!

Don

nbrunson84

Yes they are - make sure your Queries are worded carefully. We were
dinged for a Query which said to document "within the progress notes"
and the physician documented *on the Query*. (Even though a Query after
discharge is to be filed permanently with the chart.)


N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

Unknown

I am forced into a position of tracking query responses by

1. physician agreed and documented
2. no response
3. physician disagreed

It was decided in-house (not consultants) that if the physician documented any response the tracking response would be #1. This method most likely messes with the "financial" impact calculated but gives a much more accurate picture of physician response and query appropriateness.

I do not like being backed into a corner by the premade definition for the responses. The program was set up with financials only in mind but I review for specificity and severity of illness only.


Charlene

vleadbetter@cmcvtx.org

A couple of questions. In asking I am not trying to be deceitful, just trying to get a clear idea.

1. If queries are not part of the permanent medical record is a hospital bound legally or otherwise to send the queries when medical records are requested?
2. If queries are not part of the m.r. how would anyone know whether they were sent or not? I know our physicians don't make reference to queries in the medical record, we are lucky when they document an answer to our question

I would be interested in your thoughts.
Vickie Leadbetter

robert.hodges2

Queries are not part of the medical record here, but on a recent Blue Cross audit I was asked internally if I had queried and I had. I then got to draft part of the response to Blue Cross, but the query was never asked for or sent.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

dallend@einstein.edu

Queries that are not a permanent part of the medical record do not need to be sent when a medical record is requested. We have queries that are a permanent part of the medical record - they are sent with a copy of the medical record.
We do log our queries in Soft Med. If someone asks us if we have a query policy or if we do queries - we would state that we do and, if needed, provide them the information regarding the query.
As a CDS I have no idea of the charts that are requested from outside parties. The only way I know that a chart reviewed by me or one of my coworkers was requested by an outside source is by my management.

dog

Charlene, I have the same problem with the choices. Wonder if we use the same software. I am liking your response, though. Maybe "agreed" should mean, "agreed to address the question."

Sandra, as far as the "leading queries," I have been told that as a nurse, I am part of the interdisciplinary team and I am not held to the same standard as coders, and therefore I can be much freer with my queries. We're not even supposed to call them queries any more because that is a coding term; they are now "clarifications."

My queries and worksheets are scanned into HPF when the rest of the chart goes in, but when an outsider requests the chart, they don't get them. They are not considered part of our medical record.

dbutler

I know what software / consultant you're using ('clarification' & 'interdisciplinary team' gives that away).

I would suggest though that anything that waddles and quacks will still be seen as a duck no matter what it is called. Therefore, need to be careful about being reasonably complaint in regards to the standards for coding professionals.

On the other hand, concurrent activity does seem to me to have more latitude and that is one of the great values of CDI -- the direct, personal contact and the education / information shared that over time influences broader documentation habits across many cases.

Don

dallend@einstein.edu

We stopped documenting agreed and disagreed. We just document if the physician replied to the question or there was a "no response".
Our coders no longer query at all. We handle all documentation issues and, I agree, as nursing professionals, we can be a little freer with our discussions with physicians. Our facility expects us to use our clinical knowledge and experience when we discuss issues with our physicians and when we leave queries on charts.

sbeatty

This is exactly how we do it. We call them queries, but the form is
called a "clarification." We use that word A LOT when writing queries.
CDSs are not part of HI but Clinical Quality Management. Our queries are
on our computers and we print them out and put them on the chart, also a
largely paper document, especially for physician documentation. The
chart is scanned after discharge, and our queries are scanned, but are
not a permanent part of the medical record. When anyone pulls up the
chart for review, the queries aren't visible to anyone but the CDIP
team. Nevertheless, we need to be mindful of Don's comment about the
content being "discoverable."

Is there anything else I can do for you?
Clinical Quality Management would like your feedback on our ability to
meet your needs. Please complete a satisfaction survey for our
department.

Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org

"The most important thing in communication is to hear what isn't being
said." Peter F. Drucker

Unknown

Does this mean you review 100% of your inpatient charts? that is, if the coder's do not query at all?
So if the coder has a documentation question post discharge you take care of that also?


Charlene

cbarnes

We document Agree/Declined/No Response.

dallend@einstein.edu

We review Medicare and 1 Medicare HMO at this time. We do all post discharge queries for our coding staff. They refer the cases to us with the requested query. We review the case. We query if there is sufficient clinical evidence to support their request. We average about 400 queries per month. We have 3 CDS. Approx 10-15% of our queries are post discharge queries.

dog

I review 100% of the inpatient charts where they pay on the DRG, at least when I am here. I do miss the weekend short stays. If a coder has a query, they give it to me and I am supposed to get it answered, whether I reviewed that chart or not. I do get to analyze the query to see if I think it's valid before I pass it on to the physician, and if I don't, it doesn't get asked.

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

Does this mean you review 100% of your inpatient charts? that is, if the coder's do not query at all?
So if the coder has a documentation question post discharge you take care of that also?

Charlene

lspryszak

Renee:

Be aware that there is nothing to date (legally, CMS guidelines, etc.) that validate that a nurse can query any differently than a coder.

I would be very cautious to adhere to the AHIMA practice brief "Managing an Effective Query Process" until there is a legal precedent stating that nurses are held to a different standard.

Just remember, it's not the consulting firm (or whoever told you "nurses are different") who will be at risk, it's your facility (and you, if it's your "leading" query that results in a denial from the RAC or your QIO). Blame flows downstream...

I agree wholeheartedly with Don on this issue.

wfreeman

After the assessment fee, the initial cost of our software was between
$500,000 - 600,000. The yearly fees are around $100,000. Our program paid
for itself in the first few months.

Bill

Bill Freeman, RN, BSN
Supervisor of CDMP

sindhusamson

What software are you using?

wfreeman

We are currently using the JA Thomas Guide software.

Bill Freeman, RN, BSN
Supervisor of CDMP

sindhusamson

Thanks.

tiffany_susan

We use JaThomas, 3M is used by our coders, and we almost moved to:
Demers, Negrete & Associates, Inc.
18 Singer Brook Rd.
Milford, NH 03055-4272
T 603.769.3159 9am - 5pm, M-F EST
F 603.673.0590
mnegrete@demers-negrete.com
www.demers-negrete.com
www.cdipweb.com
Which ever one you choose, make sure it is compatible with the encoder
currently used by your coding dept.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program

"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

dbutler

Suggestion -- before getting shopping too seriously, design what it is you want the software to do for you. Some rapid and far from complete thoughts in no particular order. Knowing what you want will help to ask better questions (and get the answers demonstrated if at all possible)

1 -- provide an automatically updating worklist to coordinate pt ADT changes, CDS assignments, reminders, at-a-glance work needs and priorities....
2 -- data gathering -- initial reviews, re-reviews, queries, responses, outcomes.......look at the Journal and Blog for some ideas on metrics.
3 -- CDI/clinical reference material embedded (Merck, drug book, dictionary, coding clinics, proprietary information from the vendor, etc.)
4 -- electronic documentation of all CDI activities, notes, etc. with integration into the facility records (either as part of the legal medical record or as separate but available to all) vs stand alone retrieval
5 -- additional data details (specific diagnosis being queried for and with what frequency.......)
6 -- analysis & reporting -- canned only, optional facility designed, adhoc capable (user can create their own analytical reports with graphical outputs.....)
7 -- encoder capability

Review the list of exhibitors on the ACDIS 2011 Conference page -- several to a fair number of those organizations offer software elements, some free standing, some as part of their consulting work. There is a great variety of price, features, etc. and the needs of your organization are critical in that investigation process.

I want a lot of flexibility for data capture, analysis, local report design, local control, etc. May not be as important for other facilities. I've looked at 3M, Morrisey, Midas & am aware of CDIP, IDinc (there are others, but just haven't been able to take even a passing glance). All of those seem to be good candidates but depends on how good of a match for your needs.

For us, we started with JA Thomas for consulting, their software has worked well enough, but there are features and levels of integration we are now hoping to acheive, so are looking around also. One point -- look for something you might already have or be able to leverage; we already have Morrisey in place with case management and it has the flexibility and integration to build what I want (and the price is right -- no additional licensing required and the 3M encoder is integrated also without extra cost -- costs involve our organic IS team time).

Link: http://www.hcmarketplace.com/ev-8893/4th-Annual-ACDIS-Conference-Orlando-FL.html

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com


Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill

paxneros

May I ask why you did not go with cdip.web?

Thanks,

NBrunson, RHIA, CCDS

tiffany_susan

I could not justify to management the cost to switch companies.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program

email: tiffany_susan@guthrie.org
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

paxneros

I understand.

Overall what did you think about CDIP.web?

I looked at it last year at the conference but looking seriously. I thought we would go with the same company we have. CDIP has come highly recommended by other collegues as well as I've heard it is fairly budget-friendly.

tiffany_susan

We viewed there demo, it was all very comparable to most other software,
what I really liked was there willingness to adapt the program to our
needs. Very flexible, seem to understand that all programs are not all the
same. I was very impressed, wish we could have switched.

Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program

"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

paxneros

Thank you Susan!

Tailoring it to fit our needs is a definite plus. Not sure when we would be able to upgrade but we want to take a look at them and add them to the list of possibles.

~Norma

robert.hodges2

Homemade database and other commercial query tracking software. Excel for reporting metrics.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

Unknown

I think separating questions might provide more clarity. We use 3M CDIS but use/used FTI as a consulting agency to start our program.

-Jane

vdavis2

Consultant prop. Software and spreadsheets for workflow

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

cfowler

ChartWise!
Started with the consultants soon learned not much bang for my buck!
The info I was getting was basically equal to our less than what I get through CDI Talk and ACDIS.
Now use ChartWise Software Program with the caveat that if I ever feel we need some subject matter experts/outside audits etc we can have access to a subject matter expert/consultant.
With ChartWise managing my queries, the built in intelligence, RAC info, report capabilities, tracking/trending, I have not recognized a need thus far,
Honestly, I think we have an excellent community of SME's here on CDI Talk with other "official" sources available.
If you haven't seen a demo from ChartWise.... do yourself a favor and take a peek!
I have been astounded! I am happy that my one CDS has more and more time to spend in the record digging deeper and deeper to get the most concise and accurate documentation and much more time with the MDs to educate and build relationships. My CFO is exceedingly pleased with our CMI. It has been incredible! Win Win for us!
c

Carla D. Fowler, RN MBA
Director, Case Management and CDI
Colquitt Regional Medical Center
229-891-9363

lsipos@monument.health

Alvenia

Currently, we use CLARO/CDR2 and We LOVE them. They have proven very valuable to our program and provide insight and follow up annually for us. We are actually getting ready to extend our contract with them. They are easy to work with as a group-questions and feedback is timely! The software is very user-friendly and we can extract SO many areas (customizable to your institution) of information, matrix's, and productivity issues. We recently looked at many new vendors for computer assisted coding, and decided for the CDI program for our institution to continue with CLARO!

Hope this helps!

Juli Bovard RN CCDS
Rapid City Regional Hospital
Rapid City, SD 57703
Jbovard@regionalhealth.com

katysuegood@gmail.com

We also use CLARO/CDR2 and have been happy so far. That being said, this was decided prior to my arrival so I have not had the opportunity to do much research on other software options.

Juli,
What CAC programs did you look at. Our coders are going live with Dolbey CAC soon and there has been discussion about adding the CDI component.


Good luck!

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

lsipos@monument.health

Katy/CDI TALK

For CAC our top choices (coder and CDI's) were 3M and Optum/Insight. We looked at Dolbey but honestly I don’t remember IF/WHAT the CDI portion looked like. I know we looked at a few that did NOT even have a CDI component-or did not come prepared to show that with the Coding portion. (we also looked at Plato, Precise Code, and Quadramed).

For many of the vendors, it was going to be months (6-8) before they would be able to provide us with their product. That being said, our contract with Claro was up for renewal anyway. I think once the Coders choose and implement the Program we will then see about adding the CDI portion.

Hope this helps!

Juli Bovard RN CCDS
Rapid City Regional Hospital
Rapid City, SD 57703
Jbovard@regionalhealth.com

katysuegood@gmail.com

Thanks Juli!

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

lsipos@monument.health

Glad to help!

Juli Bovard RN CCDS
Rapid City Regional Hospital
Rapid City, SD 57703
Jbovard@regionalhealth.com

Unknown

Our Coding and CDI department like Optum/Insight too for CAC. It is on our wish list! We use 3M currently for CDIS software. (Not Encompass) and like it for the most part. It has some issues with accurate reports. I "clean" our data for accuracy.
Jane

nieke.oglesby

Hi Katy,
are you back from your maternity leave or you just missed us so much
that you are sharing your wealth of knowledge with us?

Anyway, good to see you actively contributing to CDI talk again.
Nieke Oglesby, RN, BSN
CDIS Baptist Health
Jacksonville, Florida.

katysuegood@gmail.com

I'm BAAACK!! I'm working part-time from home for the next several months.

Happy to be back

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

lsipos@monument.health

WORKING FROM HOME! How nice! Congratulations!

Juli

nieke.oglesby

Welcome Back! great to have you back. Hope you are having a wonderful
time with your little one. Congratulations btw.

Nieke Oglesby

alvenia.reese@ensemblehp.com

I would like to thank everyone for their response.

Alvenia M. Reese, CCS
Clinical Documentation Specialist-HIM
Beebe Medical Center
424 Savannah Road
Lewes, DE 19958
302-645-3100 Ext 5441