Many US hospitals are now reaching the end of their electronic health records roll-outs. Companies such as Epic and Cerner have reaped large windfalls from these implementations at most hospitals across the country. While the software companies have benefited greatly from the implementations, many hospitals are left scratching their heads about how best to take advantage of their new software.
Many hospital information leaders are pointing to clinical documentation improvement, or CDI, and interoperability as key areas to focus on. Traditionally, CDI was the product of humans scanning paper charts and looking for ways to extract more charges out of the work being done by physicians. With electronic health records, hospitals can now automate a lot of their CDI functions via workflow enhancements and templates. As this article by Scott Mace at HealthLeaders Media explains:
“Electronic health records, in use at nearly all U.S. hospitals and by more than three-quarters of all physicians, achieve two major objectives for healthcare systems. They facilitate generation of a bill, and they provide documentation of providers’ assessments, actions, and plans to treat patients. As the industry pivots from volume to value, the nature of clinical documentation is undergoing unprecedented change, and is driven by the way providers get paid.
This transition is challenging healthcare leadership in ways never before encountered. Changing documentation technology is often cited as a leading cause of physician burnout, in studies such as one by the Mayo Clinic in June 2016, in which 6,560 physicians in active clinical practice were surveyed.
While healthcare leaders and the industry look to evolve EHRs to make them simpler to use and their data more interoperable, and to integrate timely decision support into EHRs to make documentation more useful and meaningful to clinicians, at the same time, patterns of documentation well established under the fee-for-service model persist, confounding these moves toward simplicity.”
Read the entire article here: The Clinical Documentation Conundrum
As hospitals look to get more value out of their EHR implementations, one option will be to invest in additional enhancements and improvements to squeeze more value out of their systems. There are many tools out there that can help increase automation of CDI initiatives, which is a great place to start driving more value. Tools such as iRISupply from Mobile Aspects can help increase automation for CDI purposes, and can also alleviate the documentation burden on staff to help reduce burnout.