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Computer Assisted Coding - Project & Change Management Success!

Computer Assisted Coding (CAC) continues to be a Coding and Clinical Documentation Integrity (CDI) industry hot topic, as the logical next step in resource containment and the focus on quality improvement. Today’s burning platform is to thrive in the space where quality, compliance, and reimbursement requirements converge. Challenges continue to exist in capturing accurate and complete documentation, and in translating that into financial reimbursement and accurate quality reporting. CAC products offer a path to improvement through enhancing and marrying CDI and Coding functions, while simultaneously integrating clinical quality indicators with revenue cycle compliance and reimbursement requirements.

Goals & Benefits:

The reasons for instituting a CAC program are numerous. The following goals are all common in strategic CAC implementations:

  • Improve code accuracy and secondary diagnosis capture
  • Expedite coding processes and productivity
  • Improve case mix index
  • Increase accuracy of acuity indicators
  • Enhance CDI and coder workflows, report metrics, and collaboration
  • Improve documentation capture

Project Management:

It should be no surprise that a CAC implementation warrants dedicated project management – with many integrated technical and operational variables, collaboration between information technology, Coding, CDI and your CAC Vendor is imperative.  Defining who will work with training, vendor support resources, hardware and network engineers, interface analysts, EHR system analysts, coding, CDI, quality, and revenue integrity resources is also critical.  You need someone with inherit operational knowledge of each discipline as well as key EHR workflow knowledge and an understanding of the documentation pathways present.   

A strong CAC project manager will:

  • Provide ongoing leadership, structure, and support to all project disciplines
  • Develop and execute workflow analysis, project plans, and strategy for testing and training
  • Build and foster collaborative work and understanding among technical and operational teams
  • Highlight and manage project interdependencies – organizing deliverables between teams/components
  • Coordinate effective issue reporting, risk assessment, and issue resolution
  • Track progress across multiple project phases and teams, and communicating status and deliverables to all
  • Ensure overall quality, thoroughness, and timely completion of key project deliverables and objectives

Change Management:

As with most successful product implementations, change management is involved, and this one is no different.  The need for exclusive user adoption to “teach” the learning platforms a common recognized coding language is critical (i.e. everyone is agreeing with or declining the same codes when suggested).  A strong dose of positive and transparent change management is highly recommended to kick-off the project!  Start early with communications aimed at both project and system understanding...Why are we doing this? What exactly is changing? How do I individually need to work differently?

Additional tips for Change Management success: 

  • Define a group of superusers
  • Include superusers in project decision making
  • Understand current workflows and outline in detail how the processes will be changing
  • Perform testing with the system and interfaced documentation
  • Cater training to staff needs
  • Establish collaborative goals and project outcomes
  • Have a method to capture concerns and issues for resolution
  • Celebrate success!

CAC technology brings a major shift on how coders and CDI specialists have reviewed and processed records for most of their career.  Getting your staff to trust the new system, new CDI/Coder interactions, and leverage the system tools will be the foundation of your success.

CAC is powerful technology that allows health systems to capitalize on the gains mentioned above. The Wilshire Group encourages you to remember that a strong project management foundation, and an emphasis on change management are pillars critical to a successful install and optimization.  As always, The Wilshire Group is here to help in any way you may need.  Learn more here, or get in touch with a member of our team: https://thewilshiregroup.net/