What's In Your CDS Content? 5 Must-Have Elements


Without clinical content, a documentation system is just a word processor. Content can influence patient care quality, efficiency and effectiveness, how much reimbursement is received and much more. However, not all content is created equal. Whether content influences those things in a good or bad way is determined by how good or great that content really is.

Certain attributes of clinical content are basic requirements.  It must be created by clinicians who have real-time patient experience, and the subject matter should be appropriate for the environment in which it will be used. Practicing emergency physicians should create content for an emergency care setting, for instance. It must be evidence-based to be credible, as well, using state-of-the-art practices and methodology that follows an intuitive workflow. With these elements in place, one can deem the content to be good — the baseline for acceptable, and no more.

For great clinical content, information systems must extend beyond this baseline to provide material that helps providers arrive at the best possible clinical outcomes. The following are five critical attributes of content that reaches beyond the fundamentals.

1. Content is fluid.
The substance must be a living, breathing thing. Whether the vendor or clinicians maintain it, the content cannot be static. It should be regularly updated by industry experts to include the latest medical practice knowledge, society and authoritative guidelines, as well as regulatory mandates. Additionally, content must be consistent with the latest coding rules. Content that isn't continually maintained can quickly become stale because the industry is continuously changing.

2. It drives clinical decisions.

Great content will ensure clinicians conform to standardized care policies or best practices and provide cognitive strategies to help them recognize and respond to atypical cases. Combining the right words with an intelligent layout that utilizes human factors best practices including positioning, grouping, fonts, colors and page orientation can have a positive impact on the quality and outcome of patient care. (See illustration below).

3. It provides data for reporting.
Hospitals are increasingly required to report data to regulatory organizations, which use it to measure the impact government programs are having on healthcare delivery and to improve public awareness with sites such as CMS's Hospital Compare. Having quality data also helps improve a provider's bottom line by providing better visibility to quality trends and effectiveness. But, in order to have this reportable data, the content must be specific enough to be meaningful and usable enough so the clinician can interact with it in an effective manner. Without high-quality capture, content can't support high-quality reporting; garbage in means garbage out.

4. It supports the transition of care.
Valuable content needs to provide value for downstream providers, creating a fluid transition of care. The users' content must be converted into accurate, readable, logical and relevant information for this to take place. Structured, readable and relevant output allows the next provider to find and digest exactly what they're looking for.  On the contrary, unintelligible, voluminous text is a distraction and often disregarded, interrupting the continuum of care.

5. It drives completeness.
Content should help drive completeness of both documentation and care.  Irrespective of the delivery mechanism, paper or electronic, great clinical content provides "active" feedback. The content must call out the important items and drive completion without interruptive alerts or complex feedback. The subtle, almost subconscious alerts great clinical content provides prevent alert fatigue and interruptions that have been shown to cause errors and negatively affect patient outcomes.

To be great, a documentation solution must know how providers think, as well as what information is critical. The most vital concern is in the aspect of human interaction — to complement the personal experience and expertise of physicians and nurses while providing them with confidence and insight. Content is more than just documentation. It's the brains behind the system, and great content drives great quality care. 

Robert Hitchcock, MD, FACEP, is T-System's VP and CMIO, leading the company efforts for solving regulatory issues and identifying trends. He is a nationally recognized meaningful use expert and active member of the HIMSS Physician Committee and other HIMSS subcommittees advocating response to proposed meaningful use rules. Dr. Hitchcock is a practicing ED physician and an Emergency Department Practice Management Association (EDPMA) board member. In 2001, he earned recognition for excellence in teaching from internal medicine residents, and in the early 2000s, he trained and supervised basic and advanced life-support EMS providers. His goal is to advance system adoption and usability to improve the quality and efficiency of ED delivery.

More Articles on Clinical Documentation:
Hiring a CDI Specialist: 3 Tips You Need to Know
What Physicians Like and Dislike About EHRs
Self-Assessment for Hospitals' Clinical Performance 

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