Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation.

BACKGROUND: Numbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS review patient records concurrently with patient admissions and visits to ensure that information is accurate, complete and non-ambiguous, and query clinicians when they see opportunities for improving data. The occupation was initially focused on improving data for reimbursement, but rapid changes to clinical coding requirements, technologies and payment systems led to a quickly evolving role for CDI programs and changes in CDIS practice. OBJECTIVE: This case study seeks to uncover the ongoing innovation and adaptation occurring in a CDI program by tracing the evolution of a single CDI program over time. METHOD: We present a case study of the CDI program at the HonorHealth hospital system in Arizona. RESULTS: The HonorHealth CDI program holds a unique hybrid expertise and role within the healthcare organisation that allows it to rapidly adapt to support emergent demands both internal and external to the organisation, such as supporting accurate data collection for the COVID-19 pandemic. CONCLUSION: CDIS are a vital component in present data-intensive resourcing efforts. The hybrid expertise of CDIS and capacity for adaption and relationship building has enabled the HonorHealth CDI program to adapt rapidly to meet a growing array of clinical documentation integrity needs, including emergent needs during the COVID-19 pandemic. IMPLICATIONS: The HonorHealth case study can guide other CDI programs in adaptation of the CDI role and practices in response to changing organisational needs.

CODEX Meets RACOON - A Concept for Collaborative Documentation of Clinical and Radiological COVID-19 Data.

Within the scope of the two NUM projects CODEX and RACOON we developed a preliminary technical concept for documenting clinical and radiological COVID-19 data in a collaborative approach and its preceding findings of a requirement analysis. At first, we provide an overview of NUM and its two projects CODEX and RACOON including the GECCO data set. Furthermore, we demonstrate the foundation for the increased collaboration of both projects, which was additionally supported by a survey conducted at University Hospital Frankfurt. Based on the survey results mint Lesion™, developed by Mint Medical and used at all project sites within RACOON, was selected as the "Electronic Data Capture" (EDC) system for CODEX. Moreover, to avoid duplicate entry of GECCO data into both EDC systems, an early effort was made to consider a collaborative and efficient technical approach to reduce the workload for the medical documentalists. As a first effort we present a preliminary technical concept representing the current and possible future data workflow of CODEX and RACOON. This concept includes a software component to synchronize GECCO data sets between the two EDC systems using the HL7 FHIR standard. Our first approach of a collaborative use of an EDC system and its medical documentalists could be beneficial in combination with the presented synchronization component for all participating project sites of CODEX and RACOON with regard to an overall reduced documentation workload.

Real-World Evidence of COVID-19 Patients' Data Quality in the Electronic Health Records.

Despite the importance of electronic health records data, less attention has been given to data quality. This study aimed to evaluate the quality of COVID-19 patients' records and their readiness for secondary use. We conducted a retrospective chart review study of all COVID-19 inpatients in an academic healthcare hospital for the year 2020, which were identified using ICD-10 codes and case definition guidelines. COVID-19 signs and symptoms were higher in unstructured clinical notes than in structured coded data. COVID-19 cases were categorized as 218 (66.46%) "confirmed cases", 10 (3.05%) "probable cases", 9 (2.74%) "suspected cases", and 91 (27.74%) "no sufficient evidence". The identification of "probable cases" and "suspected cases" was more challenging than "confirmed cases" where laboratory confirmation was sufficient. The accuracy of the COVID-19 case identification was higher in laboratory tests than in ICD-10 codes. When validating using laboratory results, we found that ICD-10 codes were inaccurately assigned to 238 (72.56%) patients' records. "No sufficient evidence" records might indicate inaccurate and incomplete EHR data. Data quality evaluation should be incorporated to ensure patient safety and data readiness for secondary use research and predictive analytics. We encourage educational and training efforts to motivate healthcare providers regarding the importance of accurate documentation at the point-of-care.

Novel application of telemedicine and an alternate EHR environment for virtual clinical education: A new model for primary care education during the SARS-CoV-2 pandemic.

BACKGROUND: Restrictions to direct patient contact resulting from the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic left some medical students near graduation in need of a required critical care medicine (CCM) sub-internship. A group of educators deployed a virtual curriculum utilizing telemedicine and electronic health record (EHR) technologies. METHODS: Nine students participated in a formal curriculum of high-value critical care medicine topics designed to meet the learning objectives of the in-person experience. Students obtained patient histories and directed physical examinations virtually via telemedicine. They followed assigned patients, submitted clinical documentation, and practiced electronic order entry using a non-production EHR copy. At conclusion these students completed the same evaluation used for "in-person" CCM rotations earlier in the year. RESULTS: Students rated the virtual rotation comparably to the traditional rotation in most evaluated criteria. Lower rated areas included "perform minor procedures", "patient counseling", and "interprofessional experiences". Students' narrative responses specifically noted strengths of the "student focus" and the ability to practice in an EHR copy. DISCUSSION: Students and preceptors generally found that the virtual curriculum provided adequate educational opportunities. Certain areas were clearly lacking, as expected. Students felt the dedication of the faculty to the students' educational needs was the most important factor contributing to the success of the program. The results suggest several ways telemedicine and EHR technologies might enhance clinical medical education in the future. CONCLUSION: This methodology was successful in providing elements of a CCM rotation experience. This technology could prove efficacious for primary care rotations where in-person training is not feasible due to the SARS-CoV-2 pandemic.