Health information management

A medium-sized hospital had been using an electronic health records for 12 months. They were having great success with getting the providers to document within a timely fashion; however, many of the notes did not provide enough information to code the record and/or key components to adequately code were missing. They had a process for physician query, as follows:

• Electronically flag the record for physician query
• Create a paper query form for the provider
• Send the electronic query to the health information management operations department to put in a physician completion folder
• Health information management operations adds a deficiency to the patient chart to flag the provider of a coding query that needs to be completed
• The provider comes into the Health information management department to complete the query
• The deficiency is removed, and the query is scanned into the chart
• Health information management operations then notifies the coder, through an e-mail, that the query was answered
• Chart is coded and sent to billing

While it was a strong process and the providers did answer the questions, it caused a spike in the time to get the charts coded and to billing, as providers usually came into the department once every 20 to 25 days. In some cases, providers would leave the coding queries unanswered for up to 60 days. The average turnaround time for a coding query was 28 days. The organization needed to change the process to help accelerate the query process and reduce the physicians’ frustrations of having to come into the health information management department.

New functionality exists within the electronic health records to send an electronic query, which would automatically assign the deficiency and send a note to the provider’s inbox within the electronic health records alerting him or her that a coding query exists. The new process had fewer steps and involved fewer people; however, the physicians were concerned about the new process. With careful training and education, the new process was implemented and reduced the steps, making the physician query process easier for coding, health information management operations, and the providers. The new processes steps were:

• Electronically flag the record for physician query
• Create the electronic physician query through pre-designed templates and assign the correct physician (this would automatically assign the deficiency and send the coding query to the inbox)
• Physician electronically completes the coding query through the electronic health management
• The electronic deficiency is automatically removed and the coding query is electronically submitted to the physician and retained and the chart then automatically flagged to complete coding
• Chart is coded and sent to billing

With the change in the process, the health information management operations department has little involvement unless it is supporting the physician in completing the query. The turnaround time for completion of coding queries was reduced from 28 days to 15 days within the first 60 days of completion. The process was a success and the organization has significantly reduced the time it takes to code and bill all patient encounters.

2. Differentiate between the 10 characteristics of data quality found in the  American Health Information Management Association  data quality model.

3. What else could the facility do to improve the query process? What are the resources needed (time, money, personnel, etc.) to facilitate these potential improvements? Would these be opposed by anyone involved in the process (for example, if something is going to cost too much, the hospital may not pay for it; or physicians might be opposed to anything that compromises accuracy, etc.)?