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14 Ways Quality Leaders Can Streamline Clinical Documentation for Clinicians

Picture this: You’ve entered a cake baking contest and are responsible for baking, decorating and serving a beautiful and delicious cake, but you must rely on others to provide the correct amounts of eggs, flour, butter, baking soda, sugar and other ingredients. Oh, and someone else picked out and bought the pans and the oven. And the whole team is stressed and short on time. Happy baking!

As a quality leader at a hospital or health system, your job might feel similar to this hypothetical baking contest. You’re responsible for extracting data from patients’ electronic medical records and then reporting your clinical quality measures to CMS and other payers, but you have little or no control over the source data. In addition, clinical documentation drives medical record coding. This not only drives reimbursement for your organization but also is used by CMS to risk adjust mortality and readmission measures and other claim-based measures that are tied to value-based penalties and incentive payments. Finally, better documentation that captures the patient’s story just leads to safer and more coordinated care. With so much riding on the completeness and accuracy of clinical documentation, most quality leaders today are challenged with finding ways to more effectively engage their busy doctors, nurses and other licensed clinicians to improve their clinical documentation without adding additional workload.

The good news is that there are plenty of ways you and your quality department can make it easier for doctors, nurses, physician assistants, respiratory therapists and other providers to capture the data needed by your organization.

This article is based on our takeaways from a literature review of 20 articles, reports, peer-reviewed research and surveys related to clinical documentation. The complete list of the sources used appears at the end of this article, with links to the source materials.

EHRs, Clinical Documentation and Clinician Burnout

The clinical documentation challenge that most affects your ability to do your job is almost certainly how providers and others feel about clinical documentation, especially when it comes to documenting in EHR systems. In short, it’s an incredible hassle and a big contributor to clinician burnout. Let’s look at a few numbers that quantify the extent of the challenge.

  • 71% of physicians say EHRs contribute “greatly” to physician burnout
  • Why? 74% of physicians say using an EHR has increased the total number of hours they work each day, and 69% say using an EHR takes valuable time away from their patients
  • 44% of physicians say the primary value of their EHR is digital storage, compared with the 8% who cited clinical care as the primary value of an EHR
  • Physicians spend an average of 16 minutes on their EHR systems for each patient encounter, with most of that time spent on chart review, clinical documentation and ordering.

The burnout extends to nurses, too.

  • 52% of nurses say they spend 20 to 39 hours per week documenting patient care in their EHR systems
  • 32% of nurses who left their job cite burnout as the reason; a stressful work environment was the leading cause of burnout
  • Nurses rate their level of satisfaction with their EHR system at an average of 7 on a scale of 1 to 5, but give a 3.3 and a 2.7 to whether EHRs improve their efficiency and whether the time they spend on EHR tasks is reasonable, respectively

And if that’s not enough:

  • 68% of hospitals are planning to optimize the functionality of new releases in their EHR systems
  • 34% of hospitals are planning to add significant new functionalities to their EHR systems
  • And 11% are planning to change EHR vendors

Giving doctors, nurses and other clinicians more of what most of them don’t want to do might just make the situation worse.

To learn more about how EHR conversions affect hospital quality departments, read “5 Pro Tips for Quality Departments Facing an EHR Conversion


14 Ways to Make Documentation Less Cumbersome

Traditionally, most clinical documentation improvement efforts tend to be more reactive than proactive. Chasing down clinicians to remind them to document bacterial organisms, pre-existing comorbid conditions, or specifics of a newly diagnosed condition is not an easy or enjoyable task for quality leaders. Fortunately, there are some strategies and tactics you can pursue to improve clinical documentation at your organization. Here are 14 tips we found during our research:

1. Build additional and predictable time for EHR documentation tasks into the daily workflows of doctors, nurses and other providers. The accuracy of data capture will improve accordingly.

2. Consider hiring medical scribes to document clinical notes from physicians, nurses and other providers. This will bring a consistent level of expertise to clinical documentation and reduce clinicians’ time on paperwork.

3. Create a multi-disciplinary clinical documentation improvement committee that regularly queries patients’ EMRs to flag documentation issues. Each month rotate your focus on high volume, problem prone and high-profile populations, such as Acute MI, Pneumonia, CABG or Total Joint patients. Use that feedback in documentation training and education for clinicians, and don’t forget to include an expert Medical Records Coder on your team.

4. Create standardized and validated clinical documentation burden measures for clinicians. By measuring and tracking the burden, such as time spent on documentation, you can identify ways to make documentation less cumbersome for clinicians. Ultimately, this will reduce burnout and generate more of the data you need.

5. Create baseline measures for MS-DRG coding mix and coding depth so that you can measure progress as you improve. For example, what percentage of heart failure patients are assigned to MS DRG 291 (Heart Failure and Shock with MCC), MS DRG 292 (Heart Failure and Shock with CC) and MS DRG 293 (Heart Failure and Shock without MCC or CC). As you improve your clinical documentation, coding depth should increase, and more patients may be assigned to a higher reimbursing MS DRG. Plus, you want to be sure you have sufficient documentation to support MS DRG MCC and CC assignments so you can avoid CMS penalties for upcoding. Let’s face it, a call from the Office of the Inspector General is never fun!

6. Integrate natural language processing software into your clinical documentation workflow. Algorithms in the software check for patterns in electronic clinical documentation and flag suspect or missing data. For example, when a medical progress note contains the word “pneumonia,” the software can prompt the user to specify the organism, if known, and whether it was present or absent on admission.

7. Use tested and highly accurate voice recognition technology to take verbal notes during patient visits. The same technology can convert those notes into a common language and input them into EHR systems.

8. Integrate your pharmacy management system with your EHR system. Syncing the two systems means they’ll share data on patients’ medication history, drug contraindications and newly prescribed drugs.

9. Limit clinicians’ clinical documentation responsibilities to clinical data required to support the care of the patient. Enable clinicians to capture that data at the point of care. Delegate or automate additional documentation and measures to other team members.

10. Monitor the use of copy and paste notes by physicians, nurses and other clinicians. Overuse of the copy and paste functionality in EHRs can mask missing data and perpetuate incomplete or inaccurate data. Support staff may be enlisted to input repetitive, non-clinical and administrative data.

11. Provide regular electronic clinical documentation training and education for doctors, nurses and other providers. This will help ensure that the right data is in the right field in patients’ EMRs.

12. Review the number of fields that capture data from your clinical staff. Determine how many fields are necessary, redundant or could be auto filled. Reducing fields will make documentation less time consuming.

13. Assess your EHR screens’ design and usability for multiple simultaneous users in team care settings. More eyeballs will spot missing clinical data.

14. Improve the EHR user interface in collaboration with your EHR vendor and your IT department. Redesigning it to eliminate inefficiencies, reduce screen time and improve workflow will drive data capture.

No matter how simple you make documentation for clinicians, nothing can replace “shared vision.” You know the data clinicians enter into the EHR translates into better diagnoses, treatments, experiences, and results for patients—and ultimately, safer care. Your clinicians may not see that connection so clearly.

Obviously, clinicians aren’t attempting to provide bad care to their patients, but they may not fully understand how their little actions (like a button click) can help connect the dots in a system-wide quality improvement campaign. Each piece of data they enter provides a broader picture of what’s going on.

As the head chef in our imaginary baking competition, you must connect their individual actions to the overall goal and, if you can, make it easier on them by using these strategies.

Sources

 

Related: Learn more about Medisolv’s clinical workflow analysis and data validation support services for hospitals and health systems. 


 

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Vicky Mahn-DiNicola, RN, MS, CPHQ

Vicky is the Vice President of Clinical Analytics and Research at Medisolv. She has over 20 years of clinical analytics and product management experience, as well as a strong clinical background in Cardiovascular and Critical Care Nursing, Case Management and Quality Improvement. She has been successful at partnering with innovative thought leaders and executing strategy for new models of care delivery, case and quality management programs, performance measurement and benchmarking.

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