CDI involvement with electronic systems development

[Deleted User]

I've been speaking with a few individuals lately regarding the CDI role in the implementation of various pieces of the electronic health record. Many are frustrated with the level of involvement of CDI in the decision making process.
So I am wondering if that bears true among most facilities.
For example, if you have a computerized physician order entry system (COPE)did anyone from your staff participate on the implementation team to give advice about how a physician's orders affect other aspects of the medical record?
If your facility is contemplating an electronic health record are CDI professionals at the table to offer insight about how different aspects of the medical record affect final coding?

Unknown

They are implementing a new system at our facility and none of the CDI
nurses have any input into the process. Our HIM director is very
involved of course.

tiffany_susan

Unfortunately, our system for EHR is handed to our facility as a package
then we adapt it to our needs. It is extremely difficult to make/expect
any changes in the software. I am extremely frustrated.
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

robert.hodges2

Just my personal opinion as someone with a MSN in Nursing Informatics. You need to relay your strong desire to be involved in the process as well as what you want the system to do for you to support your work flow. Don't wait for someone to ask you. When they implemented at my last facility I pushed to get case management involved and actually ended up on the product selection team and asked questions that would impact case management and social work. What we got wasn't perfect, but then it was a lot better than it probably would have been.

Once you do get involved, or even if you don't, get all of your peers together and decide what it is you want from the system. I call it a dream list, but you have to know what you want to be able to do so that you can see how they support your workflow and functionality. I would do this in any event and send it up to your supervisor and to whoever is heading up the implementation team. If your facility considers your functions important, then they will listen. Your CFO may end up being your best ally in this.

If you don't advocate for yourself, at least to your manager and director, then you will end up with something that may not work for you. Of course you may still end up with that, but at least you have made your case and had it considered for the implementation.

Again, just my personal opinion.

Robert

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

dvitalone1

We have 3 facitilites which are currently undergoing implementation of a total electronic system. Our facility is second in line for implementation. The 1st facility has underwent transformation and CDI just now is being involved. CDI at my facility has never even seen the CDI part of EPR nor have we had any input. You are not alone!

Dawn

tiffany_susan

Very true! Any changes/advancements in our direction have come my being
involved and pro-active ...... you can't sit back and wait till it is
finished, then complain about the final product.
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

dvitalone1

Well, as great as that sounds not all facilities will allow this and all you end up doing is stepping on toes and making enemies. Trust me I have tried with no luck at all...it is what it is and hope for the best. You should be thankful you are allowed to be heard

Unknown

Although I have not been involved previously with the implementation of the electronic record regarding physician orders, progress notes, etc., I am being included in the meaningful use efforts that our IT department is trying to get a handle on. This I am finding frustrating. Luckily the coding supervisor and I are on the same page so we are joining efforts to try and make this work. Anyone else working on meaningful use?

kshumpert

I have been involved with the CPOE and building the ordersets. I will be trained a superuser to assist the physicians with their documentation as well as the CPOE. I am also on the meaningful use team. I have also participated in some of the nursing documentation as well. While this takes up a very large chunk of my time now, I hope that it pays off in the future.


Kathy
Kathy Shumpert, RN, BSN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

Writing comes more easily if you have something to say. ~Sholem Asch