The Clinical Documentation Conundrum

Scott Mace, February 1, 2017

Healthcare leaders are looking at their options for making EHRs simpler to use and their data more interoperable, as well as making clinical documentation more useful and meaningful to clinicians. Healthcare leaders have had some success, but solutions aren't coming easily.

This article first appeared in the January/February 2017 issue of HealthLeaders magazine.

Michael Zaroukian, MD
Michael Zaroukian, MD

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.

Lessons from the traditional CDI dynamic
The practice of clinical documentation improvement actually predates the EHR and, when CDI's digital equivalent is used well, has proven to be complementary to a fee-for-service world. Prior to EHRs, physicians would document on paper, and then CDI specialists within a health system would pore over these notes, flagging areas where physicians had not been specific enough. This provided several benefits: alerting the system that a patient's condition was more severe than originally documented and flagging overlooked issues such as comorbidities, but also permitting billing at a higher level, which satisfied management's goal not to leave any money on the table.

Scott Mace

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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