Chart Conundrums: Use Clinical Documentation Data to Remedy Physician Burnout
By Mary Pat Langer
For The Record
Vol. 33 No. 6 P. 28
Physicians consistently cite clinical documentation as a primary reason for fatigue, administrative burdens, and day-to-day career dissatisfaction. EHRs were meant to simplify documentation capture and alleviate the historical documentation burden. Nevertheless, physician usability issues and high levels of burnout persist.
A recent session at the American College of Medical Informatics symposium concurred that the “degree of clinician burnout and its contributing factors, such as increased documentation requirements, were significantly underestimated.”
HIM professionals play a significant role in remedying physician burnout issues. In fact, their clinical documentation data hold the key to unlocking a potential solution. It all begins with HIM leaders analyzing the data they have, anticipating which physicians will need help, and then implementing physician-specific interventions such as new technology tools, educational programs, and personalized workflows. Personalized clinical documentation workflows may include such options as enhanced templates, speech recognition, alternate means to document, or a flexible combination.
This article explores the various types of physician productivity data that exist today and gives specific examples of clinical documentation interventions that work to achieve HIM’s ultimate goal—timely, complete, and accurate notes correctly representing the care provided.
Metrics to Measure
The general end-to-end workflow of the clinical documentation process yields a treasure trove of physician productivity and efficiency data. These data determine which clinical documentation methods are most effective for each physician, including dictation and transcription, speech recognition, the use of scribes and EHR templates, or a combination of all the options.
Standard data elements such as time of day, length of time, report type, and documentation method are important items to capture, collate, and analyze. Did the physician use front-end speech, mobile voice recognition, back-end speech, or direct entry into the EHR? Each modality impacts the need for physician corrections and clarifications differently, and therefore speaks to physician efficiency and burnout.
Data within clinical documentation systems should also identify “where” physicians perform their dictation. Environment determines the pressure a physician was under when he or she dictated, used speech recognition, or keyed information into the EHR. Was it from the office or from home? Was it late at night, once the children were asleep?
These insights are important to determine the optimal way to ease clinical documentation burdens for each member of the medical staff.
Since many physician complaints arise when physicians are asked to review, rework, redo, or respond to queries, it makes sense to track the amount of time spent on those activities. Whether the physician uses dictation and transcription, virtual scribes, speech recognition, or documentation templates within the EHR, analyze the data to understand how often the physician returned to the report to review, edit, append, or respond to a query.
The number of times a physician goes in and out of a document directly correlates to physician satisfaction with the clinical documentation process. Is the physician getting “pinged” for follow up from coding, clinical documentation improvement (CDI), and case management? How many different stakeholders reach out to a single physician?
A flexible combination of modalities all supported within a single workflow is often the best way to relieve burnout and simplify clinical documentation for physicians.
Use Data Insights to Inform Interventions, Personalize Workflows
As noted, existing data determine the best intervention to pursue. Analysis of all clinical documentation data elements shows which physicians are proficient with EHR templates and which use dictation and transcription services, scribes, and speech recognition. Other technologies such as text messages, voice-to-text via mobile devices, and ambient voice yield productivity data that can be incorporated into the clinical documentation data analytics initiative.
With an eye on reducing burnout associated with rework, particular focus should be placed on the amount of self-editing required by the physician and time spent returning to a report. For example, self-editing with front-end speech recognition requires physicians to spend more time on document review, which can be an added source of frustration. Conversely, dictation and transcription include review of the report by human clinical documentation experts before presenting the report back to the physician. In most cases, this reduces review time for the physician and yields a cleaner, more accurate document.
Perhaps the optimal workflow for a specific physician involves the use of the EHR, a scribe, and a back-end transcriptionist. Multiple combinations are possible, each of which may provide a practical, cost-effective solution. When it comes to clinical documentation, finding the right workflow components for each clinician is the key to physician satisfaction. One size does not fit all.
Three Ideas to Help Physicians
When dealing with clinicians dissatisfied with documentation processes or struggling with timeliness and accuracy, HIM professionals should consider three important strategies. These steps should be based on insights gleaned from the clinical documentation data and taken in collaboration with CDI, IT, and other organizational peers.
Incorporate additional documentation options and tools into physicians’ workflows.
Physician aggravation climbs and satisfaction drops when multiple corrections and clarifications are required. Providers experiencing more difficulty with rework, editing, and documentation time should be consulted about their efficiency and offered other documentation options to improve their workflows. For example, providers who use a lot of telephony dictation could be shown mobile applications to improve their efficiency, see prior notes, access templates while dictating, and review reports. Mobile options add more flexibility and portability to clinical documentation workflow.
Expanded use of templates is another way to increase physician productivity and reduce dissatisfaction. Whether within dictation and transcription workflow or EHR systems, customized templates alert physicians of missing documentation up front. This decreases the time needed to correct documentation on the back end.
Work with your CDI team and coders to identify where high volumes of physician queries are coming from and implement prompts within the documentation templates to gather this information up front. For example, prompts can be inserted within documentation templates for physicians to specify congestive heart failure as diastolic, systolic, acute, etc.
Gathering more details from physicians at the time of dictation improves efficiency. Any type of query forces them to reopen the record, review documentation, and respond. Requiring more granularity up front relieves the workload for everyone—physicians, CDI, coders, and downstream revenue cycle billing and denial teams. Better clinical data integrity also supports more informed patient care.
Provide educational sessions in collaboration with CDI, coders, and IT.
HIM professionals should work with their CDI teams and coders to provide clinical documentation education for the providers. This can be a simple refresher on the technology tools and how to use them. If the incorporation of new, personalized dictation options is indicated, holding a more in-depth educational session with each provider is an effective strategy.
The same is true for training and retraining physicians on EHR documentation, especially as templates are updated and improved. Any updates made to the dictation and transcription templates should be mirrored within the EHR for consistency and ease of use. HIM professionals who work directly with their IT departments on this step have a valuable ally to identify inefficiencies, improve physician satisfaction, and streamline workflows.
Target physicians who are noncompliant with timeliness and completeness requirements.
As HIM professionals are aware, The Joint Commission (TJC) and others require that documents be completed within specific time frames. For example, history and physical reports are acceptable when completed by physicians within 30 days prior to admission but require an update within 24 hours of the patient’s physical arrival at the hospital.
Every report type has an associated TJC requirement. HIM should continually run reports from its clinical documentation systems to identify which physicians are compliant with those time frames and which are not.
Offering personalized documentation options and education for noncompliant physicians may ease friction between HIM and the clinical documentation process. Tap your IT support teams for additional support to fully evaluate their clinical documentation workflow and find ways to simplify. Whether outsourced or in house, use new options for call centers and clinical IT support, including at-the-elbow guidance with other clinician or EHR experts.
Accuracy and completeness of clinical documentation are additional factors to consider when targeting inefficient physicians. When clinical documentation is complete, billing becomes more accurate and quality scores are positively impacted. Other downstream benefits include improved case mix index, decreased length of stay, faster billing, reduced discharged not final billed, better facility cash flow, and lower denial rates.
Continue to Track and Measure Metrics by Physician
It’s important to track the same metrics—such as loading a mobile app, updating templates, system retraining, or at-the-elbow support—that triggered the initial clinical documentation intervention with the physician. Trend clinical documentation performance over time for the entire organization, by specialty and by individual physician.
HIM professionals have the power to simplify clinical documentation workflows for their physician counterparts by using analytics to inform better documentation options based on care setting, specialty, and physician preference. When given options that can be easily deployed, physicians see reduction or elimination of administrative burdens and become more willing to try new clinical documentation methods. The process begins with making the most of your clinical documentation data.
— Mary Pat Langer is the director of HIM Services at DeliverHealth. She has more than 40 years in the health care industry, administratively in the hospital setting, operating a medical transcription service she founded, and in leadership roles in large technology companies.
NINE DOCUMENTATION METRICS TO MONITOR BY PHYSICIAN
• Time of day
• Length of time
• Report type
• Location performed
• Documentation method(s) used
• Time spent on review, edit, correction (including self-editing)
• Number of times physician returned to same report
• Number of times physician was queried about same report
• Number of stakeholders reached out to a single physician