July 19, 2016

Gaps in Documentation: Don’t Let Them Happen to You

The information contained in the electronic patient record is the basis of every next step: it guides the questions a physician asks, the decisions made about treatment, the specialists to whom the patient is referred. When you sit down and open a patient’s record, you have to have faith that it is complete and accurate — otherwise the entire use of electronic health records (EHR) breaks down, forcing physicians to duplicate work or, worse, to miss important elements of the patient condition.

Yet that’s exactly what’s happening in hospitals, physician practices and other facilities every day. Why? Well, as a recent study shows, up to 50% of physician-patient interactions are missing from medical records. According to a recent report from the Journal of the American Medical Informatics Association, “nearly half of patient face-to-face contact with health care providers — checkups, emergency room stays, even hospital admissions — were missing from their electronic records.”

These gaps in documentation are very real, compromising quality of care and, in the worst-case scenario, posting a threat to patient safety. Here are three strategies to help ensure your patient documentation is complete and thorough, every time.

1. Overhaul your EHR

Yes, it’s a bold, expensive and time-consuming move. But according to the aforementioned study, the leading cause of gaps in documentation is that various EHR software systems are largely incompatible. There is no one-size-fits-all EHR, so in order to make a system change, you have to first spend time listing and prioritizing your practice, hospital or facility needs and goals. That will let you focus on choosing an EHR system that will be customizable to your workflow, frequently seen conditions and diagnoses, and documentation needs. If the costs, space or maintenance requirements of a server have become onerous — or you want to be free of them — choose a cloud-based provider. Put your vendor to the test, and have them propose how systems will be organized and users prepared for the upgrading process. Choose the best combination of EHR offerings and vendor efficiency.

2. Change your documentation approach

Accountable care organizations (ACOs), expanded preventive-care efforts and population health management are the future. What’s more, each of these approaches is inter-related with the others. By embracing them now, you’re better able to prepare for continuing healthcare reforms. These approaches require to you look at both technology and people solutions when it comes to documentation. On the EHR side, look for features such as an automated messaging system, to remind forgetful patients of their appointments and home-care tasks. Other items that may be on the wish list: US-based helpdesks, easy sharing with other providers in your area, and data exchange with laboratory or diagnostic systems. All these features will help ensure that every physician-patient encounter can be fully documented in the patient record.

In addition, for these more holistic approaches to work, care must be patient-centered. Patients need to be empowered and engaged, so that they, too, can contribute to the creation of thorough documentation. Sharing aggregated, appropriate data with them can make patients more active participants in managing their own care, whether it be ongoing treatment for a chronic condition, or rehabilitation after an outpatient surgery. In short, documentation needs to be a two-way street, rather than something that only physicians and providers contribute to.

3. Remove the documentation burden from physicians

EHRs were supposed to make documentation more organized and easy to use for hospitals and physicians (and, as discussed above, even patients). However, the combination of user-unfriendliness and the added effort of data entry into the electronic system has proven to be a constant source of stress for physicians and providers, which could lead to gaps in documentation. Using certified medical scribes relieves doctors of these digital record-keeping burdens and ensures the accuracy and completeness of documentation by freeing the physician to get the most out of the patient encounter. While scribes record every aspect of the patient encounter, physicians are free to delve into the patient history, have a more free-flowing conversation with the patient, and draw out more information about the condition or how the ongoing treatment plan is working. At the end, the scribe will have produced high-quality documentation that can be relied upon in the future to better direct all physicians involved in the patient’s care in making medical decisions. In addition, scribes can document post-discharge care instructions and medication information that doctors communicate orally to patients, so that a written version can be given to patients to take home, which will in turn guide them in providing information back to providers.