With love in the air for Valentine’s Day, Avaap thought it was a good time to share some of the fond (and not-so-fond) feelings our team has on electronic clinical documentation. Let’s start with what’s good:
Real-Time Charting: Before electronic clinical documentation, charts were expected to be completed within an hour of diagnosis. Even waiting just an hour, however, often results in details that are forgotten or misremembered. Through electronic clinical documentation, notes can be taken in real time during the patient encounter and accessible by others in the facility, speeding up the care process for the patient.
Storytelling Done Right: As healthcare organizations move to value-based compensation models, it’s crucial that all care is recorded thoroughly and accurately. Electronic clinical documentation allows for the combination of coded, discrete data, and “non-codable” narrative notes. This combination of information is important when documenting care in the value-based care environment as it helps tell the complete patient story and provides the organization with insights needed to move toward enhanced care outcomes.
Added Functionality: In the early stages of EHR (electronic health record) adoption, documentation was designed to resemble its paper predecessor. This might have eased the transition for some but it quickly became a downside as more information moved electronic and was accessed by billing and coding staff as well as the physician and other caregivers. Systems now go beyond mimicking paper to offer additional options for recording the patient encounter such as point-and-click drop down menus to ease information gathering and ability to customize the view based on role. Offering several ways to input data increases physician happiness and attitudes toward EHRs and ability to customize the view enables users to see information relevant to their job or role.
While there are many things we love about electronic clinical documentation, it doesn’t mean it’s all a bed of roses. EHR systems may still need some work:
Inefficient Format: Because EHR systems are designed to capture the full scope of a patient’s story, forms and templates are designed to record a wide variety of information. These system inputs can become time-consuming and cut into caretakers’ patient time. In response, many doctors are copying their notes from day-to-day rather than actually updating information in the EHR, which can cause information to be lost, making it difficult for others who rely on EHR data. Does this mean we need to “break up” with templated documentation? No way! A bit of counseling can help a lot!