Coding System Implementation Satisfied Both the Coders and Management

by Scottie Ann Frey, RHIA of the University of Virginia Health Systems

The University of Virginia Health System (UVAHS) was one of the first SoftMed clients to convert from ChartStat to ClinTrac, SoftMed's latest abstracting solution. Through this implementation, UVAHS took the opportunity to evaluate the current coding environment and implement other changes that are not directly affected by the new system.

The impetus for this project was a direct reaction to a decrease in productivity and massive system downtime hours.

The project goals and objectives were as follows:

• Reduce the number of minutes required to abstract an account
• Improve coder satisfaction
• Decrease the downtime hours for maintenance utilities

Once the goals/objectives were finalized and the implementation process began, UVAHS took the opportunity to evaluate their current coding system/environment and determine ways to improve effectiveness and efficiency. The results of this evaluation are as follows:

• Every abstract field and abstract data choice was evaluated. An owner and reason for the data collection was researched. If an owner and reason could not be located, the abstract field and/or data choice was not converted.
• The custom reports were also evaluated. The custom reports were compared to the standardized reports in ClinTrac. If a standard report would suffice, the custom report was not converted.
• SoftMed performed a demonstration of ClinTrac prior to the Kick-Off. Through the design and build process, the coders reviewed ClinTrac. They offered suggestions regarding layout and flow of the screens.
• To ensure that all changes and the owner of such changes to the new system were tracked, a change control process was developed (see below).

The program was evaluated on its benefits and positive outcomes, which are as follows by category:

Abstracting

• 73% increase in abstracting productivity (4.25 to 1.25 minutes)
• 33% decrease in the number of abstract fields (128 to 99)
• 65% decrease in discharge status options (13 to 7)
• 99% decrease in number of custom reports (39 to 1)
• Elimination of downtime for maintenance utilities (350 to 0 hours)

Reporting

• Enhanced reporting capabilities via the standard reports and query builder application
• Improved response to requests for patient data during regulatory agency visits
• Employees in Quality Assurance, the Trauma Registry, and Finance have access to ClinTrac and can run their specialized reports without the assistance of IS or Coding Services

Change Control

• Development of a change control process for all HIS systems, including ClinTrac. All changes post implementation are required to be requested via completion of the Change Request form (see attachment). All Change Request forms are maintained by the HIS Systems Analyst.

User Community

• Increased job satisfaction and morale
• Able to run concise daily productivity reports by individual
• Development of a "hold on drop bill" process for certain DRG's so the accounts may be reviewed prior to billing

UVAHS is an integrated network of primary and specialty care, offering services ranging from routine checkups to the most technologically advance care. The Health System includes a 541-bed hospital with over 600,000 annual visits. It is complemented by numerous clinics on the UVa campus, throughout Charlottesville and in neighboring counties. Coding Services consists of 18 employees, 12 of which are coders. Approximately 78,000 accounts are coded in ClinTrac each year by Coding Services.

Supporting Documentation:

Change Request Form     PDF