Ask physicians their top reason for their fatigue, administrative burdens, and day-to-day dissatisfaction, and clinical documentation woes rise to the top of the list. The problem isn’t getting better anytime soon. In fact, a session at the recent American College of Medical Informatics symposium revealed that the degree of clinician burnout was significantly underestimated.
But a potential remedy exists. And Health Information Management (HIM) professionals can find it within their organization’s clinical documentation data.
In the November/December 2021 edition of For The Record magazine, Mary Pat Langer, Director of HIM Services at DeliverHealth, revealed how clinical documentation interventions can help create timely, accurate documentation, reduce physicians’ anxiety improve their productivity.
- Capturing, collating, and analyzing data elements such as time of day, length of time, report type, and documentation method can help determine the most effective clinical documentation approaches for each physician. It’s also important to capture data about where a dictation is performed, and the number of times physicians need to access a single document.
- Analyzing all clinical documentation data can help show HIM leaders which physicians are most proficient within their EHR, and which physicians require help. This analysis will allow HIM professionals to create an optimal documentation workflow for individual physicians. One key clue to understanding a clinician’s EHR proficiency: The amount of self-editing required per record.
Langer also offers these three strategies HIM professionals can consider to improve physician satisfaction with clinical documentation:
- Incorporate additional documentation options and tools into physician workflows. For example, providers who use telephony dictation may improve their efficiency by using mobile apps instead. Customized templates may also increase physician productivity and reduce dissatisfaction.
- Provide educational sessions in collaboration with Clinical Documentation Integrity, coders and IT. These can be simple refreshers on available documentation technologies and how to use them. Plan more in-depth education if you’re adding new, personalized dictation options.
- Target noncompliant physicians with timeliness and completeness requirements. HIM leaders should run reports continually from clinical documentation systems to see which physicians meet documentation timeframes dictated by regulating bodies such as The Joint Commission. Also, look for accuracy and completeness of clinical documentation
Learn more—including a list of nine documentation metrics to monitor by physician—in the full article.