CDI-Cast, CDI and the Electronic Medical Record (EMR): Strategic considerations and operational challenges

Program Description

In this session, we discuss the importance of obtaining physician input on the EMR process upfront.  We address how to speak with your physicians about how they see the EMR impacting their clinical documentation, how to ask them for suggestions, and what to do with those suggestions. If you have already implemented an EMR, we discuss how to conduct a productive discussion with physicians about the impact of the technology on their documentation.  We then discuss how to use the dialogue to work towards improved alignment with your medical staff. You will also learn about some of the more common issues that involve both EMR implementation and clinical documentation concerns.  These include interfacing clinical documentation between two clinical information systems, education on the use of the EMR, compliance risks that can result from copy and paste or pull forward techniques, and quality care concerns when the EMR creates conflicting information from different clinicians’ entries.  

Session tools

• Inventory for EMR/clinical documentation interface issues
• Agenda for educating physicians on the use of the EMR
• Checklist of EMR compliance concerns

Objectives

• Describe how to obtain physician input on the EMR process
• Discuss how to speak with your physicians about how they see EMR impacting their clinical documentation
• Positioning the EMR and clinical documentation teams to interface seamlessly and efficiently
• Identify documentation compliance concerns with the EMR and how to minimize risk for your organization

Intended audience:

• Clinical documentation managers
• EMR implementation team managers
• Health information managers
• Physician documentation leaders
• Compliance reviewers and managers
• Information technology managers
• Coders
• Medical staff managers

CDI-Cast Self-assessment: 

Assess your program by answering a few key questions that will be provided at the end of the session.  Use your responses to improve your current CDI program.

Q&A:

You can submit your questions on the CDI-Cast Web site.  We will address as many of the questions as possible and post responses on the Web site.  Responses will only be available for CDI-Cast subscribers to view.

Take-aways

• Add clinical documentation to your EMR agenda
• Review any current EMR or  computerized physician order entry (CPOE) practices to minimize compliance risk
• Schedule a small group discussion with a few supportive physicians to ask about their concerns regarding the impact of EMR on their documentation using the format described in the session

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