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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
Briefing: Implementing EHR is More than Pushing the On Button

Date: 21 March 2007

Time: 0900 - 0950

objectives
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?
what is ahlta
What Is AHLTA?

ACRONYM MEANING?

This is an actual name, not an acronym!

pre deployment
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?
pre deployment1
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
during
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
during1
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
reports
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
during2
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
during3
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
slide11
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!
slide12
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
policy review development
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)
policy review development1
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