by Mary Butler
The HIM Problem
To improve the efficiency and productivity of its clinical documentation improvement (CDI) program, Baystate Health decided to train CDI specialists to work from home.
The HIM Problem Solvers
Walter Houlihan MBA, RHIA, FAHIMA, director of health information management (HIM) and clinical documentation, Baystate Health, and Jennifer Cavagnac, CCDS, assistant director, clinical documentation improvement, Baystate Health.
Transitioning to a Remote CDI Workforce
As hospitals and integrated health systems start to rely increasingly on electronic health records (EHRs), an unexpected benefit may very well be happier health information management (HIM) staff. Coders have long been known to work from home, but Baystate Health, which is based in Springfield, Massachusetts, took things a step further by moving their CDI specialists off-site as well. The goal—and the results so far—include more efficient and accurate work.
In 2011 Houlihan and Cavagnac wrote a white paper for the organization’s internal use, outlining the Baystate HIM department’s approach to CDI in the past and how it hoped to overhaul the program to stay current with the evolving coding and reimbursement environment. In the 2011 paper, Houlihan and Cavagnac noted that Baystate had initially launched a CDI program 12 years prior. This, of course, was when CDI was in its infancy and resources—such as best practices, training, and credentialing programs—weren’t as extensive as they are now.
Like many hospitals at that time, recruiting and retaining coders posed a challenge, so Baystate kept its CDI staff at a minimum and gave them a post-discharge focus, “that would strive to achieve the desired outcomes of the CDI program in addition to addressing the need to maintain an adequate coding workforce,” the white paper said.
Then in 2012 Houlihan and Cavagnac started making plans to grow their CDI staff and eventually transition them off-site. In January of 2013 there were two full-time CDI specialists and two more were being hired. Due to their recent success rates, in 2014 Houlihan and Cavagnac received approval to expand their CDI team from four to 10 people. They currently are able to review approximately 25 percent of the cases from the primary hospital campus, and two community hospitals, which comprise 758 beds total.
The initial group of four CDI FTEs started doing CDI on-site for a good six months until they were transitioned to working from home. When they were working on site, they grew familiar with Baystate’s EHR, and developed good working relationships with physicians and coders, and routinely queried physicians via e-mail. This method of querying physicians served CDI specialists well when they worked on-site, so it was a natural process when they worked remotely.
Using e-mail and EHRs to run queries, “the providers are able to treat and care for their patients and not having that interruption during the care process and when they do the documentation,” Cavagnac explains. “It’s a workflow that’s reasonable for them, getting that message in an e-mail as opposed to someone catching them at a difficult or busy time when they’re caring for patients.”
To get the off-site CDI program in place and to keep it on track, Baystate developed a multi-department steering committee—comprising case workers, revenue cycle representatives, quality, medical, and surgical staff, among others—that met weekly at the beginning of the program, and then started meeting monthly.
“So it’s been a wonderful progression in the development of the program, and a lot of top-level engagement to help send the message of the importance of the goals of our program,” Cavagnac added.
How it Works
In many hospitals and clinics CDI specialists typically work on the hospital floor where they can ask nurses and doctors about queries directly. But according to Cavagnac and Houlihan, not much has changed in working from home.
“I want to stress that both CDI and coders report up to me, the collaboration between these two groups is a requirement, and they learn from each other. CDI people have experience with coder’s knowledge, and clinical knowledge,” Houlihan says.
All of Baystate’s CDI specialists have medical training, either as nurses or physicians (they have one physician CDI specialist).
The HIM department has deployed software that helps CDI and coders communicate about cases, including a technology that lets coders see exactly what CDI is inputting in a record. And both coders and CDI work closely with Cavagnac and the coding supervisor to reconcile cases in the event that there’s a mismatched DRG assignment. They have developed trend reports that enable them to measure CDI and coding quality in order to enhance educational efforts.
“Within our application, the coders, when they come up with the final DRG, if it doesn’t match the DRG that CDI comes up with, there’s an opportunity or a space for them to articulate their thoughts as to why the DRGs are different.”
Additionally, Baystate has a system-wide instant messaging platform that coders and CDI specialists can use to communicate with anyone they need to—be it billing, medical, surgical, or within the HIM departments. The CDI specialists and the coders also meet on-site regularly for orientations and to review reports on productivity and accuracy.
“We don’t interrupt the productivity of our individuals by having them pair or mentor off another individual, but we use these tools to understand where the variations [such as DRG mismatches] lie and where there’s other opportunities,” Cavagnac adds.
Improved Job Satisfaction
Houlihan says the primary reason for moving CDI specialists off-site was to boost moral by giving employees flexibility, as well as boosting recruiting and retaining hard to come by CDI specialists.
“We encourage the team to communicate with each other as a group and as individuals if there’s a quick question about a case, or a scenario, they can reach out to any of their peers and colleagues to ask a question, or just to break up the day and say, ‘Hey, how are you,’ and still have that connectivity. We don’t want anyone to go home and feel isolated completely working on their own and needing to and feeling they don’t have the resources nearby,” Cavagnac says.
She notes that while both remote coders and CDI specialists are given parameters about the security of the home environment they’re working in—they’re required to use a landline for phone communications, for example—but having the comfort of a custom-made work environment is a huge benefit.
“The key is the flexibility, says Houlihan. “With CDI and coders, we have that flexibility with work schedules. So if somebody comes to Jennifer or me and says, ‘Can I be off on Tuesday or work Saturday or Sunday because of my kids,’ we have built in that flexibility. If they can keep their performance levels while attending to their personal needs, there is no reason to deny their request.”
"Building a Remote CDI Workforce"
(Journal of AHIMA),