By David Lareau
Clinical documentation can be a tremendous source of physician frustration. Capturing patient information can be cumbersome, chart notes don’t always reflect a patient’s complete clinical status, and completed records are often difficult to translate for quality reporting, reimbursement, and chronic care management.
However, with strong clinical leadership, collaboration between clinical and IT, flexible documentation tools, and well-thought-out processes, clinical documentation has the potential to improve the quality of patient care and physician productivity and satisfaction.
Phoenix Children’s Hospital (PCH) realized these benefits after rolling out a clinical documentation improvement (CDI) program across its ambulatory health clinics.
Here’s how they did it.
Start With the End Goal in Mind
When implementing an EMR across its clinics in 2014, hospital leaders recognized the need to streamline clinical documentation processes and facilitate the creation of specialty and disease-specific templates that supported improved clinical outcomes. Before a single IT solution was put in place, PCH developed a forward-looking plan that prioritized patient care and included a well-considered vision for the project’s end goals.
PCH’s Vice President and Chief Medical Information Officer Vinay Vaidya, MD, led the IT efforts for the initiative. The project kicked off with several months of meetings with physicians to identify their clinical documentation requirements and understand key challenges. Vaidya and his team understood that to gain widespread adoption, it was essential to gather—and apply—input from clinical end users.
From the information-gathering process, IT and clinical leaders jointly identified the need for a solution that accomplished the following:
• produced structured documentation to advance PCH’s population health management efforts;
• helped improve the management of patients with highly complex, chronic conditions;
• supported physician workflows without diminishing productivity; and
• offered clinically dynamic documentation tools that allowed PCH’s small IT team to build templates quickly for the organization’s more than 30 pediatric subspecialties.
Only after concluding extensive due diligence did PCH initiate the selection of an IT solution. And then the hard work began.
Establish Strong Clinical-IT Collaboration
PCH’s CDI initiative followed a well-governed process that relied heavily on collaboration between the IT and clinical teams. Clinical usability was a high priority, as was making sure clinicians could easily capture clinical information that addressed each division’s unique requirements for documentation, reporting, and quality-of-care initiatives.
The organization took a rolling approach to the implementation, focusing on one or two clinical divisions at one time. Physicians within each division would initially meet with the IT team to review specific needs, but not before the IT staff had invested time trying to gain a deeper understanding of each specialty’s unique requirements.
Team members reviewed chart notes, billing data, and medical literature in advance to ensure the best use of the doctors’ time during the physician meetings. This extra effort improved physician buy-in and built the foundation for strong collaboration.
Each division met with the IT team over a seven- to 10-week period. During the sessions, IT queried physicians about workflows and needs to identify what measures required tracking to support improved clinical outcomes and reporting needs. Between meetings, the IT staff updated templates, then collaborated with clinicians again to fine-tune templates.
PCH’s well-defined and collaborative approach to its CDI implementation resulted in the creation of robust templates, efficient workflows, and engaged physicians who recognized the value of their new tools. Documentation is more accurate, physicians are more productive, and clinical outcomes have improved.
Across all the ambulatory clinics, clinicians have adopted the clinical documentation tools and use disease-specific templates to accurately and completely capture patient information. More than 97% of the information is entered in a structured format, allowing documentation data to flow to a data warehouse and populate clinical dashboards that provide visual representations of patient populations and individual patients. The dashboards give physicians at-a-glance insights into how patients are progressing and what actions are required to address care gaps.
Other successes include the following:
• Timely documentation. The new CDI tools and processes have helped physicians complete their charting on a timely basis, with 56% of all documentation finished by 5 PM on the day of services. About 95% of all documentation is completed the same week as the patient visit, and only 5% is finished over the weekend.
• Better chronic disease management. The clinical dashboards, which are populated from the clinical documentation, provide physicians with comprehensive, longitudinal views of each patient. This has helped doctors as they manage the care of patients with chronic disease. The previsit planning process, for example, is now automated and creates patient-specific reminders for tests and procedures. Clinicians are better prepared before patients arrive and visits run more smoothly, which also improves patient, caregiver, and physician satisfaction.
• Financial savings. Since implementing the CDI program, PCH has virtually eliminated transcription in its ambulatory clinics, creating an annual savings of $1 million.
Plan for Continuous Improvement
A final element of PCH’s successful CDI strategy is the continuous enhancing and tweaking of existing processes.
The clinical and IT teams remain committed to the ongoing improvement of their clinical documentation based on user feedback and evolving needs. The organization adheres to a well-governed and structured process to optimize templates and workflows, add new quality measures, and maximize user productivity. In addition, the IT team dedicates two to three weeks to each division every 15 months.
Thanks to PCH’s well-planned, collaborative strategy, clinical documentation is not a source of physician frustration but rather a boost to patient care and physician satisfaction.
— David Lareau is CEO of Medicomp Systems, a physician-driven provider of clinically contextual patient data solutions.