Tips for More Efficient EHR Documentation

It is widely understood that EHR documentation is the leading cause of physician burnout in healthcare. Since EHR’s permeated deep into medicine some 10 years ago, care providers and thought leaders have been leading the charge towards substantial EHR improvements and harnessing innovative methodology to mitigate its crippling ramifications.

In an ideal world, EHR documentation helps increase positive patient health outcomes and drive better reimbursement for clinicians. In practice, however, seeing a tangible return on the time spent on EHR documentation can be difficult, and striking the balance between documentation quality and efficiency has proved to be a monumental challenge for health professionals. 

Below is a list of six EHR documentation tips that care providers can leverage to deliver better patient outcomes, manage their documentation, mitigate burnout and maximize their reimbursement.

Quality, not Quantity

For years it has been wrongly assumed that the key to effective EHR documentation is to document as much of the encounter as possible, and that doing so produces better patient outcomes, reimbursement rates, and protection from malpractice lawsuits.

The reality is that note quality is much more important than note quantity. Over-documenting irrelevant information can crowd a patient's health record and make it difficult for clinicians and their staff to locate the proper information when needed. This is not to say that EHR documentation should be tenuous, in fact, it’s quite the opposite. Medical diagnostic coding regulations as implemented in ICD-10 require EHR documentation to be very detailed. But it’s not about pure volume, necessarily, but rather specificity. The more detailed the clinical documentation is, the more likely it is that clinicians will see boosted reimbursement. 

Use Templating

The fundamental dilemma in the current documentation model, however, is that in order to produce these hyper-specific, ICD-10 compliant notes, clinicians must sacrifice tons of their own time. Any brief drop off in documentation quality and the risk of a malpractice suit or EHR audit increases dramatically. 

This is why many experts suggest using EHR documentation templates during patient visits to help guide the conversation as it moves through the patient’s medical and procedural history and into the clinical assessment and recommended care plan. These templates can be designed to capture necessary ICD-10 data in a way that is thorough, safe, and efficient.

These templates should be designed to capture structured data as it relates to medical coding as well as an open text field where the provider can include any supplementary information. Templates should also be specialty-specific and visit-specific, as the nature of a patient encounter changes depending on what type of care they are seeking and where they are in the care cycle. Providers must also avoid complacency in their template designs, and should be working with their teams to ensure each template is under continual review and running at optimum.

It should be noted that clinicians should be cautious when using templates and ensure that they are properly documenting and updating any changes in the patient's record (lifestyle, other care received, prescriptions, etc.). 

Work with EHR Vendors

While well-designed templates can assist in EHR documentation efficiency, it’s critical that providers work with EHR vendor representatives to make sure they are optimizing the software. Vendor representatives can help design customized workflows that are specialty-specific which can be especially valuable to care organizations that are managing bigger teams. Specialty representatives might consider working with these EHR vendors to optimize their workflows and templates on behalf of their team so as to maximize documentation efficiency and stay up to date on software updates and ongoing platform changes.

Give Patients Access

While templating and optimizing workflows can speed up in-visit documentation, it’s important that clinicians aren’t importing non-static patient health information into every note without updating or confirming its status. Examples of fluid patient health data include things like self-reported smoking status — information that is likely to change between visits. Mindlessly importing this information into any subsequent patient note can pose risks to documentation efficacy. This is why it’s important to give patients access to their electronic health records and ask them to update or confirm non-static information — a process that is now being required and enforced by the federal government.

In April 2021, the United States government implemented the 21st Century Cures Act, which requires care providers to make available notes regarding consultation, history, procedures, and progress (among others). This access is designed to increase transparency and patient understanding of conditions, care plans and expected outcomes.

In addition to the positive health outcomes that this level of transparency can create, giving patients access to their electronic health record can ensure patients and providers are on the same page, specifically in regards to historical patient information. It’s also quite likely that in the coming years appointment management programs like EZ Arrival will grow to include patient confirmation of health information, specifically of non-static data like the smoking status example listed above. Clinician wary of blindly importing pre-recorded health history might consider taking advantage of these methods to help expedite in-visit documentation while also offering increased likelihood of positive outcomes and patient satisfaction.

Hire a Nurse Informaticist

Nurse informaticists can be a good option for providers who are having a difficult time coordinating with an EHR representative to assist in workflow design. Nurse informaticists are professionals who specialize in workflow management, nursing science, data science and analytics. Many care providers use nurse informaticists to help them integrate new technology and design optimized EHR documentation methods. 

“Nurse informaticists serve a dual role as both EHR system users and experts in technical design and data analysis,” writes Kate Monica for EHR Intelligence online. “They are uniquely positioned to optimize EHR systems for quality and workflow improvements that cater to the needs of clinical staff.” Research also shows that using nurse informaticists to optimize EHR documentation processes can improve productivity, efficiency and care coordination among different providers.

Some nurse informatics roles are contract positions that can be leveraged by care organizations of any size as a low-stakes investment into more efficient EHR documentation methods. 

In-Visit Documentation

It may be obvious that documenting a patient encounter during the visit itself is more efficient and effective than relying on extensive information recall after the patient leaves, but documenting during a visit can be difficult for clinicians to do by themselves. It’s recommended that clinicians who want to document during a visit consider investing in one of the many medical documentation solutions that are available today. Common options include medical scribes, transcription services, in-visit dictation tools, or a fully ambient AI scribe that can help complete EHR documentation. While each of these solutions have clearly outlined advantages and disadvantages, they generally help clinicians be more efficient, and can be a good solution for care providers struggling to stay on top of their clerical work.

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