Integrating Clinical Documentation Improvement into the Doctors Workflow

We know doctors are under an ever increasing load may eventually break their backs..if nothing else its increasing the overall pain

In a recent study of physician attitudes toward clinical documentation technology and processes clinicians the majority of clinicians said they would be more responsive to Clinical Documentation Improvement (CDI) clarifications if they were delivered in real-time within their normal documentation workflow in the electronic health record (EHR). They report being “disrupted” by queries for additional information

after they’ve documented in a patient chart or worse, after the patient is discharged.  All believe that ICD-10 will make matters much worse

With #HealthIT a growing portion of how doctors do their jobs they want to be involved in technology decisions yet most were not involved in clinical documentation technology decisions for their organization. And timing is everything – going back to answer questions after you have left the patient or worse after the patient has left “the building”.

So what is the difference between success and failure of a CDI program

As the study points out physicians’ growing dissatisfaction in being

saddled with processes that distract them from clinical care, while being excluded from the decision-making process of choosing things that impact them every day

Technology should be simple and work for physicians and the key to changing the experience is to eliminate rework

Rework in clinical documentation is the enemy of efficiency

As Brian Yeaman, MD CMIO for Norman Regional Health System puts it

Using things like CLU and applying that to the ICD-10 code book to help me refine that diagnosis or ask me whether it’s the left or right or an upper or lower extremity are tremendous because it has a significant impact on our bottom line, and it’s also a physician satisfier … and on the back side we are not getting so many coding queries

And Reid Conant, MD President and CEO of Conant and Associates says

“Now we can provide our physicians with tools to get real-time feedback to not only change that document, but also change their behavior for the next document. That’s what organizations are looking for, and frankly, that’s what the doctors are looking for.”

We can achieve ICD10 compliance without breaking the back of clinicians


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