AI Can Improve Clinical Documentation, Reduce Physician Burden

AHIMA and 3M describe benefits of artificial intelligence in improving clinician workflows.

Healthcare systems can utilize technology to generate data integrity and data compliance, as well as improve workflows, and achieve value-based care models, according to a new white paper from American Health Information Management Association (AHIMA) and 3M Health Information Systems.

Following the direction of an expert group of clinicians and clinical documentation integrity (CDI) professionals, the resulting white paper, Elevating Clinical Documentation Integrity with Compliant Technology Adoption, describes the benefits of computer-assisted clinical documentation.

“When CDI is done well, it can lead to better patient care and reduced burden on physicians,” said AHIMA President Katherine Lusk, MHSM, RHIA, FAHIMA. “Artificial intelligence-supported technologies like computer-assisted physician documentation (CAPD) are game-changers for patients and providers alike, taking time-consuming work and processes and creating actionable information that can lead to improved health outcomes.”

Done right, CAPD frees up physicians from some administrative duties, which lets them spend more time with patients. Patient care can be improved by ensuring accurate, complete, and actionable data. CAPD can also positively impact billing processes, lessening headaches for both health systems and patients.

"CAPD not only streamlines the physician's documentation workflow and makes it more efficient, it puts the focus back on patient-centered care for the provider,” said Shirlivia Parker, MHA, RHIA, CDIP, CDI unit manager for UC Davis Medical Center.

One component of CAPD is artificial intelligence (AI) technologies. “CDI programs supported by AI are able to deliver more complete and accurate data to providers in real-time, which helps close gaps in clinical documentation and care delivery,” said Elizabeth Guyton, vice president of 3M Health Information Systems. “With CAPD, physicians have more time to focus on patient care.”

Another key component is identifying physician champions to lead CDI education efforts that resonate and address physicians’ concerns. The panel highlights the importance of starting early, by educating residents on the importance of clinical documentation. Because residents are often responsible for starting documentation on a patient encounter, this ensures safer patient handoffs, the report states.