Today's Practice: Changing the Business of Medicine | Page 11

Doing Documentation Right

A Balancing Act
for Physician Practices
By Alok Prasad, RevenueXL
When medical group practices decide to implement
or upgrade an electronic health records system, they
often go full throttle throughout the process – that is
until they hit a roadblock with clinical documentation. Even if physicians were on board before go live,
once the technology has been implemented, they
often complain that documentation in the application takes too long, or it’s too burdensome of a
process to take on with their patient load.
But no matter how expensive or fancy an EHR is,
without clear, accurate, populated documentation,
the technology can never help deliver the clinical care
and operational benefits that many group practices
expect from it. And now that the integrity of patient
data within EHRs is required for participation in the
Centers for Medicare and Medicaid Services’ (CMS)
and other payers’ financial incentive programs, accurate documentation by physicians and other staff is
extremely imperative to nearly all aspects of any
practice.
There are, however, a few things that practice leaders
can do to avoid and overcome the documentation
derail before and after they go live with an EHR.

Choosing the Right Technology –
Templates or Free Text
When analyzing EHR options, it is important to
ensure that the technology enables physicians to

truly “tell the clinical story” — and to do so efficiently. Remember, each and every patient has a unique
clinical story. As such, the EHR must enable the
physician to recount the particulars of each patient’s
situation in great detail and with great efficienc
To support this dual objective, practice leaders
should understand their providers’ approach to
documentation. They should develop a specific,
thorough and comprehensive approach to data input
for their practice that is based on these documentation preferences. Then, they need to find an EHR
that can fully accommodate these preferences –
while also enabling speedy and accurate clinical
documentation.
Implementing technology that is not up to snuff is
likely to result in frustration. According to “Electronic Health Record Use a Bitter Pill for Many
Physicians,” a report published in Perspectives in
Health Information Management, clinicians often
find and use “workarounds” when the technology
does not mesh with their needs. For instance, when
systems are awkward to use, physicians often choose
to dismiss the EHR during the patient encounter
and instead complete required documentation
sometime after treating the patient. In such situations, physicians often take notes on paper during
the patient visit and then rely on this information to
complete EHR data entry later. Such workarounds
could actually make EHRs less efficient – and add to
physician workload.1

TODAY’S PRA C T I C E: C HA NGI NG T HE BUS I NES S OF M EDI CINE

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