Taking The Sting Out of Patient Care Documentation

By Shane Peng, MD, chief clinical services and innovations Officer,  IKS Health.

Shane H. Peng
Shane Peng, MD

“Not enough time with my provider” or “my doctor isn’t listening to me” are among the top five complaints of today’s patients—and those frustrations haven’t changed much over time. Providers feel these pressures more than ever as they are pushed to provide quality care and patient engagement for less cost, while adding to their clinical documentation requirements with less time to do it.

These and other demands have driven providers to find more streamlined, digital solutions to help them save time, while government regulations (MIPS) and health plan providers have made mandates further increasing clinical documentation and reporting requirements.

These factors have led to the challenges of the last decade as stakeholders attempt to find ways to ease charting and administrative tasks during the patient appointment and unlock physician time. The federal government and commercial payers even offered mandates to encourage providers to onboard new technology aimed at optimizing performance.

Unfortunately, these technologies have not had the effect everyone had hoped for, and in fact, have sometimes amplified physician burdens rather than reducing them. Charting in an EHR can sometimes be time-consuming, difficult, and distracting, particularly when tackled during the constraints of the visit. This has led to physician frustration and stress, and worse, errors, as time pressures mount and they are asked to speed documentation while maintaining accuracy and making the appointment more patient-centered.

To lessen the strain, many providers opt to complete documentation after the appointment, often after normal business hours. However, this can quickly burnout physicians as they work a full day seeing patients and then spend their free time finishing up charts. Most physicians report an additional two hours of documentation time per work day. This can unfortunately also lead to more mistakes because the physician is documenting based on the memory of the encounter, which is inherently flawed in terms of accuracy and comprehensiveness.

It’s clear: “The way we’ve always done it” isn’t working

Although organizations appreciate the need to free physician time and smooth the documentation process, they frequently struggle to determine the best ways to realize change. It can be tempting to fall back on traditional methods like ramping up provider training or tweaking the EHR adding customized templates to hopefully streamline workflow.

However, organizations are beginning to see that these conventional tactics aren’t overly effective, and they need to approach the problem from a different angle. Entities must find means to remove the burden from physicians while still ensuring precise and thorough documentation that supports better patient care, stronger quality reporting and tighter reimbursement.

A fresh look an enduring problem

One strategy receiving some attention involves voice-based documentation tools, which marry technology with external clinical expertise. This kind of solution uses a microphone and secure software to record a patient-physician appointment. After the visit concludes, the recording is encrypted and accessed by an offsite physician partner who creates an accurate, detailed clinical note based on the treating physician’s previously defined preferences, practice style and specialty requirements.

The note then enters a quality control process where two or three additional clinicians review the note and the recording for accuracy and comprehensiveness ensuring coding, clinical quality measures and detailed prescription information are all captured. Once documentation is complete, the treating physician reviews, edits and signs off on the note by the next morning, all within the organization’s existing EHR.

There are several ways in which voice-based documentation addresses the previously mentioned pain points physicians currently face:

Allows for more focused interactions with patients. Because the provider is not physically documenting during the patient encounter, he or she is free to concentrate on the patient, asking questions about his or her symptoms, exploring different concerns and getting a full picture of the individual’s condition. Not only does this make the patient feel valued and heard, it helps the physician better understand the individual’s condition, perspective, social determinants and other factors that could impact his or her health.

It can also qualify the visit for appropriate HEDIS or Medicare coding as the physician can ensure they are asking the appropriate questions and fully exlaining and documenting causes and outcomes. This unfettered attention can lead to faster diagnosis, more appropriate treatment, a stronger patient-physician rapport, timelier patient education and other things that can boost quality outcomes and patient health.

Removes the burden of documentation. By working with external physician partners, providers are no longer bogged down by documentation work. The voice-based option all but eliminates any after-hours tasks and can eliminate to two hours of documentation time per day. While the physician still must scan the note and sign off on it, this takes a fraction of the time, freeing the doctor to spend more time with patients, accept additional appointments or enjoy a stronger work-life balance.

Ensures accurate and thorough coding. Because the virtual scribe is an experienced physician who is focused solely on fully documenting the patient encounter, organizations can be confident that any documentation is comprehensive and complete. The high-level of detail enables better quality while ensuring appropriate reimbursement and avoiding compliance issues, such as over-coding or under-coding and even elevate HCC scores.

Cultivates continuous performance improvement. Since providers are paired with the same virtual scribe, a relationship builds over time, supporting greater collaboration. The virtual physician partner becomes an extension of the clinical team, fluent in the provider’s specific processes, standards and culture. This allows him or her to provide valuable insight on possible practice improvements, offering both an outside perspective and an internal view.

It’s a new era for documentation

Physicians have wrestled with the challenges of documentation for a long time. Increasing regulatory requirements, mounting time pressures and underwhelming technology have only made things worse. By embracing new ways of tackling documentation, such as using a voice-based, virtual scribe solution, organizations can lift the burden from physicians while enabling high-quality care and robust patient and provider satisfaction.

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