Can Performance Analytics Impact the EHR Clinical Documentation Conundrum?

The following is a guest article by Michael Clark, CEO at DeliverHealth.

EHRs have been implemented for nearly two decades in healthcare and many usability issues still remain. Of these, one of the top issues reported by physician users in virtually every EHR usability study is clinical documentation. The ONC concurs. As stated in their February 2020 final report, “In practice, EHR systems and the way clinicians interact with them to complete documentation tasks often add to administrative burden.”

In Healthcare IT Today’s recent article on automating EHR documentation, the use of ambient clinical voice is recommended as one solution to the EHR clinical documentation conundrum. But, today its impact is limited, expensive and only specialty-focused. Until ambient clinical voice is widely available, what else can be done to simplify clinical documentation processes, procedures, and workflows? The answer lies in wider use of data and performance analytics to inform a variety of documentation options based on care setting, specialty and physician preference.

EHR Is the Modern Age Documentation Tool, but Issues Remain

U.S. hospitals and health systems have spent billions of dollars on EHRs to digitize the episode of care. But if physician usability issues remain, how will healthcare providers ever achieve an ever-inceasing return on their investments? The answer is to focus on EHR usability. A recent study by the American Medical Informatics Association emphasizes this point.

Usability issues can be addressed through a multifaceted approach that includes better training, reengineered workflows, user personalization, and fewer EHR customizations. A step-wise strategy to assess and optimize one EHR function at a time has emerged as a pragmatic, cost-effective approach to EHR optimization and activation. Given that clinical documentation is the bedrock of contuity of care and medicolegal representation of the care episode, it remains a top physician concern, executive consideration and EHR priority.

This article delves into how performance  analytics and personalization are being used to streamline clinical documentation and make better usability a byproduct of physician engagement with the EHR.

Create Optionality to Capture Documentation Right the First Time

Documentation is essential to everything in healthcare: ongoing clinical care, reimbursement, physician communications, and more. This places the burden on health IT professionals and care team members to:

  • Implement the most productive, effective and accurate method for capturing the patient’s complete story
  • Pull insights from workflow, EHR build and clinical notes to inform care
  • Capture documentation once and use many times to inform downstream processes

“Capture once, use many” must be the guiding principle for all health IT teams looking to solve the clinical documentation conundrum. Capturing clinical documentation right the first time ensures that data contained in clinical notes can be used many times for downstream processes, procedures, and operations inherently reducing the physician burden. Structured data abstraction through NLP, ML, AI techniques within the unstructured text minimizes and then eliminates re-work.

While some physicians are extremely proficient with EHR templates for clinical documentation, others still lean on dictation, scribes and speech recognition with human clinical documentation experts in the background to clean, correct, and review system output. Physicians are also encouraged to use the automated documentation tools within EHRs such as text messages and voice-to-text tools using mobile devices.

But what is the best method to capture clinical documentation for each physician and in each situation? The answer lies in using performance analytics to inform physician-specific clinical documentation workflows and various personalization methods.

How to Use Clinical Documentation Performance Analytics

Every clinical documentation system captures an exorbitant amount of data regarding the physician, the type of clinical note, day and time, etc. Operational data within the clinical documentation workflow can be analyzed to determine physician-specific patterns, trends, gaps, and best practices.

For example, performance data shows which surgeons dictate their operative reports immediately following surgery and which ones wait days or even weeks after the surgical episode. Failure to promptly produce reports causes delays in coding, billing, and reimbursement. Armed with this intelligence, health IT teams in partnership with physician leadership and health information management (HIM) become more prescriptive in how they address documentation gaps and EHR usability issues.

If a surgeon is a high biller for the hospital, perhaps investing in a scribe is the best solution. The scribe can be inserted directly into the documentation workflow. Or perhaps the optimal workflow involves the use of the EHR, a scribe, and a back-end transcriptionist. Multiple combinations are possible and provide a practical, cost-effective solution in this case scenario. Finding the right workflow components for each clinician is the key to improved process automation and EHR usability when it comes to clinical documentation. One-size does not fit all.

Incremental change and improvement builds confidence in further change and adaptation advances for end-users. When given options that can be easily deployed, physicians see reduction or elimination of administrative burdens and become more willing to try new clinical documentation methods. Having options—informed by clinical documentation performance analytics—eases EHR adoption through effective personalization of technology.

Personalized Options Yield Good Clinical Documentation

Ambient clinical voice, artificial intelligence, and other advanced technologies all hold significant promise. By working together with existing clinical documentation tools and underlying performance analytics insights, organizations can begin to solve today’s EHR usability challenges.

Independently, these solutions aren’t always effective. But in combination, they deliver better and more actionable insights to offer options for physicians, improve EHR usability, and cut operational costs.

About Michael Clark

Michael Clark serves as CEO of DeliverHealth and has over twenty years experience with EHRs and clinical documentation technologies.

 

   

Categories