EHRs are vital to enhanced clinical documentation

EHRs vital for enhanced clinical documentation

As physicians across the health care industry aim to enhance care quality, they are working to improve essential tasks like data input and diagnoses. However, one of the most important aspects of care delivery that physicians must improve in order to achieve better care quality is clinical documentation. Not only can documentation errors cause serious problems like misdiagnoses, but even small mistakes can be very time-consuming and costly to fix. 

EHRs help health professionals enhance clinical documentation
Clinical documentation should provide physicians with accurate information regarding the services or procedures performed on their patients as well as patients' clinical status. Many practices and facilities have implemented clinical documentation improvement programs as a strategy to enhance care quality. 

The American Health Information Management Association explained that these programs work by transferring patients' medical data into coded information that then becomes part of quality reporting, public health data, disease tracking and claims reimbursement. To make sure that accurate and useful data is captured, health information management professionals work as clinical documentation specialists and coding experts.

Most clinical documentation improvement experts require that providers implement electronic health records into offices and facilities in order to enhance clinical documentation. High-quality EHR systems ensure that there are fewer errors during documentation and lower the amount of time that it takes to fill out paperwork and organize files. 

Specialists have also been focusing on ICD-10 implementation as they help push providers toward improved documentation processes. In addition to encouraging the adoption of EHRs and preparing for ICD-10 implementation, clinical documentation improvement experts also assist physicians in confirming that they are being compliant with patient documentation requirements. 

According to the AHIMA, hiring specialists with the proper knowledge and education when implementing these clinical documentation improvement programs is one of the most important requirements to follow. This ensures that the process is easier and less time-consuming. Providers must also continuously train and educate their staff, as well as report all treatment plans, medical decisions, outcomes of tests and other procedures. 

Companies work together to achieve high-quality care
Nuance Communications, Inc. and medical care predictive analytics business Jvion are two companies that have partnered to improve clinical documentation by helping providers adhere to the requirements of value-based reimbursement models. This is one of the many changes that practices are starting to make as they strive to improve documentation. This switch from a fee-for-service payment model to value-based care will likely have financial benefits for practices. 

Many programs help health professionals and their staffs make the transition from one payment model to the next. The Advanced Practice CDI from Nuance Communications is one such program. 

"We want to get paid for the quality of care and services we provide," Joann Hatton, director of utilization management and clinical documentation management at Heritage Valley Health System in western Pennsylvania, said in a press release. "It's not about the money, it's about improving patient care, but the positive financial impact of Nuance's CDI program was clearly evident."

For Heritage Health System, the predicted mortality rate decreased by 27 percent after implementing clinical documentation improvement strategies and clinical quality metrics.

"Data drives our practice," Jennifer Woodworth, director of Clinical Documentation Integrity Program at Swedish Health Services, noted in the press release. "Physician and hospital compensation is tied to quality metrics, which means to prove that you are providing high quality care you need data. This real-time reporting allows us to drill down to ICD-9 and ICD-10 codes, complications and other specialized details to see how we are doing with the accuracy of physician documentation, and this enables us to create proactive initiatives that maximize our current resources."

As providers continue to adopt tools like EHR systems and implement clinical documentation improvement programs, patient care outcomes are likely to continue improving.