How to Be More Efficient with Medical Documentation
Efficient medical documentation. All doctor’s offices, clinics, and hospitals strive for it. But it doesn’t happen in a vacuum. Complex patient care environments mean documentation must work within a dynamic system. Further, what would be an efficient medical documentation system in one office may not be an effective solution at all in another.
There are some common themes, though, that can help direct you when you’re developing an efficient medical documentation system for your office environment:
Team approaches help relieve the documentation burden on clinicians
Mono-tasking beats multi-tasking
Note timeliness is an important consideration
Physician burnout causes a cascade effect
Finding solutions that recognize and address these factors will help offices, clinics, and health networks create more efficient medical documentation systems. Medical dictation is one tool that can address all four areas to improve office efficiencies and, ultimately, patient care.
The Communication Bottleneck: Efficient Medical Documentation a Perennial Problem
Searching for the most efficient medical documentation system is nothing new. From the beginning of medical transcription, physicians and clinicians wanted to find the best approach for documenting patient encounters. The goal of medical documentation is simple: to provide clear and concise notes about the patient’s medical history to make it easy for the physician and other health professionals to access and understand in the future.
However, technology (as it often does) created a schism. There are many reasons why EMR systems cause disruptions. Perhaps the biggest misstep was the expectation that physicians could take over all medical documentation based on the assumption that electronic medical records (EMRs) were “easier” to manage.
Of course, that assumption turned out to be false. Eliminating medical documentation services such as medical transcription was a broken promise that led to clinicians spending more time managing patient records.
Dr. Atul Gawande wrote about the mounting frustration physicians are feeling in a New Yorker article, Why Doctors Hate Their Computers. He told of one primary care physician, Dr. Susan Sadoughi, who noticed she was spending much more time with patient records when the office switched to a new system. Initially, she was optimistic; she understood how the technology could help streamline patient care. But the system she was forced to use seemed the opposite of efficient medical documentation. The software created a “massive monster of incomprehensibility,” in her words.
“Most days, I will have done only around 30 to 60 percent of my notes by the end of the day,” she said about the new system.
Dr. Gawande commented, “The rest (of her patient encounter documentation) came after hours. Spending the extra time didn’t anger her. The pointlessness of it did.”
It is a fascinating article about efficient medical documentation – or lack thereof – and the “insidious ways that the software changed how people work together.”
Going from “Pointless” to “Efficient” Medical Documentation
Dr. Gawande and Dr. Sadoughi are not alone in their frustrations. They make a very good point: it’s not that technology is inherently a roadblock to good medical documentation. There are obvious advantages to EMRs. It’s the implementation – and in particular, the expectations around a physician’s time and skills – that is the problem.
In other words, inefficiency is not a technology problem. It is a human workflow problem.
There are four ways doctor’s offices, clinics, hospitals, and health networks can improve human workflows right now:
Mono-tasking over multi-tasking
Improving note timeliness
Reducing physician burnout
This should be obvious: the more people working on a particular task, the faster it gets done. Equally obvious should be: that the person most suited to a task should be the primary person doing that task.
However, EMR systems have steered medical documentation in a different direction. Often, physicians are solely responsible for documenting patient encounters. We must go back to a team approach for more efficient medical documentation.
“Physicians who use a scribe or team documentation generally are more productive (and get home earlier), and the increase in productivity outweighs the extra staffing costs,” according to Dr. Jay Winner.
Physicians and clinicians who use the medical transcription or virtual medical scribes are much more efficient. That’s because this team approach to documentation means that they can focus on what they do best – seeing patients – while trained documentation professionals take care of documenting the patient encounter. As Dr. Winner points out, that increased productivity often means seeing more patients for more billable hours, offsetting documentation costs by a wide margin.
Note that this doesn’t necessarily mean that the physician has to give up documentation altogether. Clinicians can use a hybrid system if they prefer, filling in the EMR with the information they are comfortable doing and using dictation for more nuanced notes.
2. Mono-tasking Beats Multi-tasking
We’ve probably all learned by now that multi-tasking is a mythical skill. Yet every day, clinicians have been put in situations where competing priorities fight for attention. Documenting patient encounters is one of them. Concentrating on filling out the EMR means clinicians must remove their focus from patients. Often, it can feel like the clinician is working for the EMR, not the other way around. If there was a way to eliminate multi-tasking, physicians could spend more time talking with their patients.
Medical dictation services and virtual medical scribes help do just that. It is much faster to take a quick dictation note while the patient is in the room than to hunt-and-peck notes. You could argue that dictation is still multi-tasking, but the difference is that attention is drawn away for seconds at a time and requires much less concentration. Therefore, it is easier to switch between tasks and keep more attention on the patient.
For those who write notes by hand and fill the EMR later, dictation is still faster. The average physician types at 30 words per minute, compared to dictation at 120-150 wpm. That means the clinician finishes notes four or five times faster, leading to more efficient medical documentation.
3. Note Timeliness is Important
Many clinicians have stipulations to submit patient notes within 24 or 48 hours of the patient encounter. In these cases, timeliness is built in. However, this can add stress and contribute to physician burnout (see below) – especially considering many physicians spend more time than ever with patient records.
But there is another reason why timeliness is important: accuracy. Simply put, “Prompt documentation reduces the risk of you forgetting key details.”
If a clinician is sidetracked for any reason, such as a family emergency or a power outage, vital details might never make it to the patient record. Dictating notes during the patient encounter reduces this risk for more timely notes and more efficient medical documentation.
Using any team documentation approach, including virtual scribes and medical transcriptionists, speeds up documentation time.
4. More Help Lowers Physician Burnout
We’ve talked about the negative impact of clinician burnout before. That’s because it has such an impact on our healthcare system. One study identified four key elements to the doctor-patient relationship: trust, knowledge, regard, and loyalty. It also found that physician burnout profoundly affects all four elements, reducing patient care – not to mention physician satisfaction and well-being.
The study identified documentation burden as one of the causes. “The amount of paperwork and documentation that is often required also enhances physician burnout, making it harder for the physician to demonstrate empathy and caring,” the study’s authors wrote.
Clearly, establishing an efficient medical documentation system that takes much of that burden off the physician and clinician will reduce physician burnout, increase physician well-being, and improve patient care.
Contact iMedat for Efficient Medical Documentation Solutions
iMedat’s team of medical transcriptionists and virtual medical scribes can help you develop efficient medical documentation solutions. Contact us to learn how we can help:
Reduce documentation burden
Streamline medical documentation
Improve speed and accuracy
Increase clinician productivity so they can see more patients for higher billables
Call us directly at 888-779-5888 or fill out our email form, and let’s create a more efficient medical documentation system for you right now.
Blog is originally published at: https://imedat.com/how-to-be-more-efficient-with-medical-documentation/
It is republished with the permission from the author.
