Better documentation processes needed for good data

“Doctors are not excited about EMRs but they are enthusiastic about speech recognition,” said Adem Arslani, BSN, RN, MS, director of information systems and clinical informatics at Advocate Good Shepherd Hospital in Chicago. Success requires a large investment in training, knowledge and information constantly, he said. “You can’t do it without the right resources. You can tell a lot about an organization by their training.”

Arslani spoke as part of a panel discussion on the role of documentation in all of the mandates facing healthcare delivery organizations.  

Advocate has three different EMR systems in use so his strategy was to install speech recognition and deploy it through the cloud. Dramatically increasing the number of the organization’s powerlinks made it possible for physicians to get support right away. “We made an $800,000 investment in our infrastructure just for physicians and it was an investment worth making.”

Michael Lee, MD, director of clinical informatics for Atrius Health in Boston, said he is feeling the intense regulatory burden but that “care coordination is our greatest clinical challenge right now.” Organizations are working on processes to capture quality measures and “it’s getting easier. Measuring and getting a good understanding of what we’re doing can help physicians and other clinicians understand why we’re installing the system,” he said.

Solid documentation practices are critical for successful quality measuring. Arslani said half of his organization’s documentation was from dictation and transcription and the other half was from the EHR and paper. “How can we make good decisions without all of the information?” Once they implemented speech recognition tools, only 4 to 6 percent of clinicians are using dictation or transcription.

The panel members all said they support whichever method their clinicians want to use in an effort to support better documentation. “We’re input agnostic,” said Lee. “We love providing doctors with options,” said Arslani.

“We encourage dictation in front of the patient,” said Hal Baker, CIO of Wellspan in Pennsylvania. “The physicians are more present with the patients and [the patients] can correct [the documentation] if necessary.”

Baker says one problem is that most physicians haven’t had their notes critiqued since their internship. Wellspan now requires everyone to put the most important information at the top of the record so that all care providers understand what’s going on with the patient. That formatting is “not negotiable.”

Eastern Connecticut Health Network has had a clinical documentation improvement program underway for almost a year, said Charles Covin, VP and CIO. Today, discharge summaries are ready within two hours and progress notes within one hour. “We haven’t had one doctor complain about documentation.”

“At one time, notes were for communication between providers,” said Baker. “They were for effective, meaningful communication” not just coding.

However, ICD-10 will draw upon thorough documentation more than ever before. “ICD-10 is really critical to us,” Baker said. “We’re getting ready for a deficiency in productivity.” Charts are queried three times—by the social worker, the documentation improvement specialist and the coder.

“You either do revenue-biased coding or quality-biased coding. You can’t do both,” he said. As we trudge toward the ICD-10 implementation date, hopefully issues like these will be addressed.

The panel discussion was hosted by Nuance and held during HIMSS13 in New Orleans.