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Briefing: Implementing EHR is More than Pushing the On Button Date: 21 March 2007 Time: 0900 - 0950

Briefing: Implementing EHR is More than Pushing the On Button Date: 21 March 2007 Time: 0900 - 0950. Objectives. Debrief on AHLTA implementation and sustainment What went right? What process(es) could have been improved? What should we do now?. The role of the coder and coder/auditor

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Briefing: Implementing EHR is More than Pushing the On Button Date: 21 March 2007 Time: 0900 - 0950

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  1. Briefing: Implementing EHR is More than Pushing the On Button Date: 21 March 2007 Time: 0900 - 0950

  2. Objectives • Debrief on AHLTA implementation and sustainment • What went right? • What process(es) could have been improved? • What should we do now? • The role of the coder and coder/auditor • What can I do at the start? • What can I do along the way? • How can I help sustain methods?

  3. What Is AHLTA? ACRONYM MEANING? This is an actual name, not an acronym!

  4. Pre-Deployment • Checklist (non-MID!) • Coding and collections on board? • Clinical champions identified? • Ensure the file and table is correct for the clinician type • Meet with implementation team? • Do we know the business plan impact? • Do we know the major procedures and diagnoses in each clinic? • Who is being trained, and when? Who are the other students?

  5. Pre-Deployment • Receive standard and super-user training • Meet with other coders, clinicians, and management already experienced using AHLTA and auditing visits • Meet with clinicians and review top 10 ICD-9 codes and top 10 CPT codes • Work with clinician to pick best templates for documenting care that maximizes appropriate workload capture

  6. During • Ensure the providers attend the class • All clinicians • All support staff • All coders • All clinic managers • All medical record and patient administration staff • Ensure the over-the-shoulder training occurs in an effective manner • With the appropriate coder • Use real cases • Set up favorites immediately • Find out what each provider needs from the system

  7. During Clinic Management • Implement a process for the managers to be the template resource • They should be able to set up • Documentation templates • Clinic favorites • Provider favorites • Assistance with this process • Templates • Electronic documentation templates in AHLTA • SF600 overprints, hardcopy • Favorites • List of most used diagnoses • List of most used procedures

  8. Reports • ADM and AHLTA Compliance, this will verify what the coders already know • Who is using AHLTA? • Who is still using paper-based documentation? • Shows whether the clinic is receiving credit for their workload • M2 and ADM productivity reports • Has there been a change in ICD-9-CM reporting? • Has there been a shift in RVU production? • Coding compliance scorecards can be provided • By clinic • By provider

  9. During • Coders and collection staff • Know what is expected in the documentation • Individual clinicians: • What does the clinician like about AHLTA? • What does the clinician dislike about AHLTA? • Work to their strengths • What do the report cards say? • Who is over-coding? • Who is under-coding? • AUDIT! • Discuss results with the command • At the directorate, department, and individual provider level

  10. During • Meet with clinicians four to eight weeks into rollout or after they have begun using AHLTA • Review templates that they use to ensure they are accurately capturing coding • Review their technique for completing the Disposition Section with ICD-9, CPT, and E&M codes • Provide statistical analyses pulled from AHLTA and CHCS to show our success with coding compliance and documentation in AHLTA

  11. Post • Vigilance • Review reports • Review records • Report results • Train with the sustainment trainers (where they have been deployed!) • Keep talking with the clinical champions • Educate new clinicians and support staff • Go back to vigilance!

  12. Post • Meet at a defined interval (at least quarterly) with business office, clinical leadership and clinicians to review coding accuracy and assess opportunities to improve coding • Be part of the sustainment team that meets with new clinicians to: • Learn successes and challenges at previous commands • Determine best practices they may bring with them • Cooperate with classroom training and command indoctrination

  13. Policy Review/Development • Hybrid Record Environment • Identifying challenges • Legal Record (How is it defined in a hybrid environment?) • Document/Record Management • Workflow Changes • Record Completion • Compliance Review (EHR and paper) • Important Elements of Medical Record Policies • Policies and procedures for: • Forms and templates • Voice recognition and dictation • Access, privacy, confidentiality, and security policies • Mental health notes • Sensitive PHI access (i.e. HIV encounters)

  14. Policy Review Development • Additional Elements of Medical Record Policies • Policies and procedures for corrections (Hybrid records – records scanned into AHLTA) • Printing Guidelines (scope and reason for printing) • Data Integrity • Reconciliation of electronic processes • Assessing potential data corruption • Downtime policy and procedures

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