Improving efficiency, outcomes and revenue with documentation solutions

Healthcare organizations and physicians are under tremendous pressure. In addition to the burden of the pandemic, providers must comply with more regulation and provide an improved patient experience while operating with lower margins. Physicians today have more responsibility and stress than ever.

Reducing documentation burdens and cognitive overload are key to maximizing efficiency, outcomes and revenue. 

During a webinar held in January hosted by Becker's Hospital Review and sponsored by Nuance Communications, four chief medical information officers (CMIOs) for Nuance Communications discussed the documentation environment in care settings such as emergency departments (EDs), surgery and outpatient care, and how computer-assisted physician documentation (CAPD) can help. The CMIOs on the panel, moderated by Greg Holland, Nuance's director of solutions marketing for CAPD, were:

  • Robert Budman, MD, 
  • Reid F. Conant, MD 
  • Rizwan Pasha, MD
  • Bret Shillingstad, MD

Five key takeaways:

  1. Healthcare organizations face pressure from all sides. Healthcare organizations must deal with administrative overload, compliance risks, patient obligations and revenue pressures. There is more information that physicians must document and prove in order to get reimbursed.

  2. CAPD has come a long way. The artificial intelligence-driven solutions available today solve a key problem in documentation, which is interpreting and deriving value from the massive amount of unstructured data that documentation yields. "EMRs have supported templated documentation, but it's a blob of text, not discrete data needed for registries," Dr. Shillingstad said.

  3. Complete, AI-assisted real-time documentation can improve patient diagnoses and outcomes. In one case, an ED patient with a very high potassium level went into cardiac arrest. A feature that flags elements like high potassium levels for physicians can help avoid missing that. "It's that kind of real-time support and guidance that can not only improve the document quality and the experience for the providers, but also, very directly, improves patient care," Dr. Conant said.

    Dr. Budman noted that CAPD can help provide more precise diagnoses as well. "Clinical communication improves," he said. "For example, I say diabetes and congestive heart failure. That's a great diagnosis, but it's not as powerful as diabetes Type I, poorly controlled with retinopathy, nephropathy and neuropathy; that's a better clinical capture of what's really happening."

  4. A CAPD solution must not complicate the physician's workflow. Physicians may initially groan when they hear about CAPD as yet another system and workflow intrusion. "But if you do it right, and if you really focus on what matters to the individual provider and to the patient, that's really where you're going to get the win," Dr. Pasha said.

  5. As margins tighten, CAPD's cost efficiencies have great appeal. Like everyone else, physicians are facing squeezes brought by rising inflation. They're also subject to cost pressures like recent Medicare cuts, and depending on their care setting, fewer patients because of COVID. "If you can increase productivity, increase revenue while seeing the same cases, that's an all-around win," Dr. Shillingstad said. "I think this tool is a no-brainer, and it's the right solution at the right time."

There's arguably never been a time where providers are more burdened than today, with increased patient caseloads and staff shortages. An intuitive, easy-to-use AI supported strategy rich CAPD solution can help ease the strain.

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