We have changed and adapted to a rapid influx of electronic medical records and data over the last several years and it’s no surprise that some systems have struggled to keep the pace. Electronic medical records (EMRs) are in a state of constant revision to make sure patient care, clinical functionality, and data security measures are keeping up with our needs. It seems there are software application solutions or enhancements to almost every task we do in healthcare and these systems are also constantly evolving.
I don’t know of any healthcare application system or workflow that has remained static year over year and because of this, it is important for us to stay on top of vendors and keep an eye on current and future needs of HIM workflows. Clinical Documentation Improvement (CDI) is one of those areas that has been evolving since it first came on the scene and it is currently undergoing yet another face-lift. We realized there were many revenue opportunities hiding within inpatient clinical documentation and found that we could maximize reimbursement with a little detective work and physician education along with sophisticated software tools. Many are exploring the idea of CDI for outpatient levels of care. This means we will need software applications, interfaces, and expanded CDI workflows to extend these opportunities to outpatient documentation. Have you thought about what you will need from your vendors to adapt or upgrade current systems and how much will need to be budgeted for?
As we work to implement computer assisted coding (CAC) programs, we see opportunities to increase coder and CDI productivity and capture even more quality documentation by using discrete EMR data to our advantage. But are these CAC systems ready to be pushed to the limits to enter unchartered waters? I personally do not have a CAC success story to tell as of yet, but I am exploring the options and hoping that these systems have matured more than when we first explored them a few years ago.
That’s the beauty of technology in healthcare; if a product does not meet your needs, there may be other options already on the market or rapidly developing new technologies on the horizon. A vast amount of data may be held hostage in our systems if we do not maximize our EMRs and applications and set our standards high in a quest for knowledge. We can’t rely 100% on technology to dictate what we do which is why we need to be the visionaries and demand more from our systems in order to accomplish new and exciting things in HIM.
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