AHDI News

AHDI Healthcare Documentation Integrity Conference 2015

By Carrie Boatman, CHDS, AHDI-F

Wow! What a conference. It started off in Washington, D.C., on August 7, and it was awesome. This year’s focus was on documentation integrity and each session focused on a different aspect of that complicated process. Attendees were given an opportunity to hear about various aspects of the process to give them a broader and deeper understanding of all the moving parts.

There were several presentations that addressed the query process used to drill down on specific information necessary for ICD-10 coding. We all know it’s vitally important to have the information, but how to ask it in an appropriate manner so there can be no hint of “leading” the physician was addressed by a number of speakers. One had an interesting idea of opening up the EHR architecture to allow health care documentation specialists (HDSs) to do direct queries of providers to assist in speeding up the process. For example, if the HDS is doing an operative report for a total hip and the provider fails to identify the components used (eg, metal, metal on metal, ceramic, etc), there would be a mechanism built into the platform to allow the HDS to simply query in a straightforward manner. This saves time and effort downstream for coders and others who analyze the documents for statistical and medical information.

Several presentations discussed methods to engage physicians in the documentation process. One facility actually took several HDSs and trained them to interact with the physicians to teach the providers how to effectively and quickly address the necessary parameters for their specialties in relation to ICD-10. They discovered that once the providers understood why this information needed to be specific and detailed, and had someone working with them to help them accommodate these details into their daily workflow, they responded much more quickly and embraced the process. They also discovered that a little competition between services went a long way.

One of the most powerful presentations was by Leana Wen, MD, MSc, FAAEM, an emergency department physician who told her personal story about two patients and the outcomes of those encounters. She now shares this information with other clinicians to encourage them to actually spend time listening to patients tell their full stories before ordering expensive and sometimes totally unnecessary tests.

Nick Mahurin, CEO of Infraware, updated us on the Health Story Project. It has now been adopted by HIMSS and has become a powerful voice in the industry to advocate for hearing the patient’s whole story.

And in between sessions, we had opportunities to meet with vendors and get the latest and greatest information on products and services being offered to the documentation community. Of course, we also had ample time to catch up with friends and make new ones at the M*Modal reception.

Overall, I have to say that having attended almost 25 conferences over the years, this one stood out as exceptionally diverse and interesting. It gave attendees a broader view of the current state of health care documentation and of the intriguing possibilities for the future. I can’t wait to see what happens next year in Milwaukee!

— Carrie Boatman, CHDS, AHDI-F, is a past president of the Association for Healthcare Documentation Integrity. She has worked in numerous positions throughout the industry with a passion for certification and quality documentation. She is currently employed by Amphion Medical Solutions as a proofreader on the Green Team.