At the Ohio State University Wexner Medical Center, compiling information into its electronic health record is more than an exercise in documentation—it’s the start of a process that has clinical relevance.
“We really see the use of the electronic health record as an extension of clinical practice,” says Andrew Thomas, MD, chief medical officer of Ohio State Health System and senior associate vice president of Ohio State Health Sciences. “The EHR is an integral part not just of documenting what we do but also driving decision support.”
For example, by leveraging data collected in its Epic electronic health record system, OSUWMC’s biomedical informatics department was able to develop, implement and evaluate methods and applications for predictive modeling of medical data.
In recognition of its efforts, the medical center has received the AHIMA Grace Award honoring its leadership in the area of health information management.
The multidisciplinary academic medical center was presented with the award at last week’s AHIMA annual convention in Baltimore. AHIMA’s Grace Award recognizes healthcare organizations that demonstrate outstanding and innovative approaches to using health information management (HIM) as a way to deliver high-quality care to patients.
“The organization’s HIM staff assisted with these efforts by helping to define data sources, and making sure identified predictors were captured in the record, and documented conditions were coded accurately,” states the association. “By acting as the ‘interpreter’ between clinicians and data analysts, and liaisons to the leadership decision-making process, the OSUWMC HIM professionals ultimately enhanced patient care.”
In addition to AHIMA’s Grace Award, Thomas notes that the medical center is also a two-time winner of the HIMSS Davies Award.
Thomas adds that its EHR system has enabled OSUWMC to expand from data collection to analysis in order to provide more effective, efficient evidence-based patient care in a timely manner by leveraging predictive modeling including the Modified Early Warning System—a tool used by nurses to help monitor patients and improve how quickly a patient experiencing a sudden decline receives clinical care.
“We’re recognizing potential problems in real time, so cases can be put into the process and reviewed as quickly as possible,” he says, pointing out that Patient Safety Indicators (PSI) are used to help identify potential adverse events that might need further study.
Liz Curtis, administrative director of Medical Information Management at OSUWMC, says the center collects and tracks PSI information concurrently.
“That’s a joint collaboration between our Chief Quality Officer and clinical staff as well as HIM professionals,” observes Curtis. “We work together to address any potential Patient Safety Indicators as soon as they are identified and then change practices in order to minimize occurrences.”
Thomas credits the fact that OSUWMC’s Medical Information Management department reports directly to him in his capacity as CMO providing an “innovative” organizational structure driving the success of the center. “What we’re pretty proud of is that we see this group as integral to the care of patient,” he exclaims. “It’s a front office not a back office function, as much as we can make it that way.”
“By putting its HIM department in leadership positions, the OSUWMC has positively impacted EHR implementation, health information exchange, clinical documentation improvement (CDI), and patient safety indicators review,” states AHIMA. “These contributions are most visible through a robust CDI program that saw improvements in capture and query response rates, as well as a 40 percent improvement in patient safety events and significant improvement in CMS quality programs including value based purchasing.”
In the case of CDI, that’s an area where HIM is “very much on the frontlines in working with the clinical staff,” adds Curtis.
“HIM professionals use the Epic system to help clarify with the clinical staff what’s happening with patients and make sure the documentation in the EHR is complete and timely,” she concludes. “They also partner with the coding specialist staff in order to ensure that entries in the record related to patient diagnoses are accurately translated into the precise ICD-10 codes for reporting purposes.”
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