Documentation has become a critical, central part of healthcare. Accurate documentation is needed for effective care delivery, measuring quality, coding and billing and much more.
However, asking clinicians to spend more time on documentation — when almost 50% of clinicians are burned out and almost 20% are burned out and depressed — doesn’t make sense. Clinicians need solutions to lessen the documentation burden and increase the value of the data in documents.
Solving documentation at the point of care was a major theme in a roundtable sponsored by Regard at Becker’s 10th Annual Health IT + Digital Health + RCM Meeting. The roundtable was led by David Kirk, MD, chief medical officer at Regard.
Five key takeaways were:
- The digitized era has dramatically transformed the patient chart. The SOAP note, created in the 1950s, was a three- to four-sentence note, built for clinicians with a sole focus on improving communication and care.
Now, in the digital era, the types and amount of information in the patient chart have exploded. Today, in addition to information about care, the digital patient chart has data about quality, HCC, SDoH, coding and billing, denials and appeals, CMS reporting and more. “We’re using it [the patient chart], especially the electronic medical record, for not what it was designed to do,” Dr. Kirk said.
- With the explosion of healthcare data, humans can’t keep up. With a single patient record now containing on average 50,000 data points, clinicians can’t keep up. On average, physicians can only review up to 3% of available data, meaning that 97% of patient data is unseen by physicians. Issues due to clinical insights gaps include missed diagnoses, suboptimal care, inefficient workflows and lost revenue.
- Transforming healthcare requires a documentation strategy. Most healthcare organizations are on a transformation journey, seeking to improve their quality of care and their patient experience while lowering their costs. Transformation can’t occur without a documentation strategy. “You can’t go from an average system to a good system to a great system without working on documentation in multiple ways,” Dr. Kirk said.
- Proactive documentation can set up clinicians for success. With physicians only reviewing 3% of available patient data while still spending too much time on documentation, a better approach is needed.
Regard is solving this through “proactive documentation” where AI reviews 100% of the data and generates a note for the provider before they see the patient. Regard also recommends diagnoses and provides supporting evidence. This sets up the clinician for success.
- Truly solving documentation involves people, process and technology. In solving the documentation challenges, the solution is not solely adopting AI or any other technology. As with any major transformation, the solution requires people, which means gaining clinician trust and adoption, along with process changes to sustain accurate documentation, and technology.
“It’s ultimately the people, the process and the technology,” Dr. Kirk said. “It is us sitting at the table, working with docs, developing those processes and implementing the correct technology.”
