By: Jeremy Zasowski
What happens when clinical documentation strategies to meet Meaningful Use requirements don’t line up with an organization’s strategies to improve clinical documentation for coding and profiling?
In my interactions with our customers, we’re seeing an increasing number of hospitals moving to increase their physicians’ adoption of template-based EHR documentation workflows. The primary reasons include: the need to move away from hand-written, paper-based notes; the need to leverage the huge investment made in an EHR; and, the requirement to meet Meaningful Use criteria for their EHR.
Using template-based documentation provided by most EHR vendors allows for documentation to be available almost immediately for communication with the rest of the care team, which is important especially for daily progress notes. Choosing templates over dictation-transcription eliminates the variable of transcription turnaround time, which can range from a few hours, to a day or more. Templates also allow documentation to be created in a consistent and structured format, with up-to-date problem lists.
There are clearly many benefits associated with the use of templates, however from what we’re hearing there also are a number of drawbacks to this strategy. Coding, communication with other care providers, and physician efficiency can all be impacted by template-based documentation. We’re seeing that physicians don’t capture as much information when they fill out a form-based template as they do when they are allowed to capture the patient narrative in their own words, either through writing or dictating. Key information may be missing, which impacts both the care team and coding—and could result in the dreaded “every patient looks the same from the documentation” issue. Some physicians tell us that templates slow down their daily workflow, making them frustrated with their organization’s EHR implementation.
Some of our large customer sites that have moved to template-based documentation have approached us about engaging our clinical documentation services. Why? They’ve seen their case mix index drop. Their physicians don’t capture as much information when they fill out a form-based template as they do when they capture the unique attributes of each patient encounter in their own words through writing or dictating.
Is it just a problem of physicians getting used to a new documentation method, or are these legitimate problems with the underlying concept of templates? Also, how does the adoption of ICD-10 and the huge increase in additional information needed to meet ICD-10 coding standards impact templates and physician use of templates in the future? What do you think?