Analyzing Clinical Documentation Requires Discrete Data

How many of your patients’ paper medical charts look something like this?  How many similar piles are on the front desk of the OR? The PACU managers office? The scheduling department? Your office?

I know it’s not pretty, it’s legible…barely, it’s written free hand, it’s clunky, it’s outdated, it’s like hearing your favorite song on an 8-track or cassette tape, it’s simply a thing of the past. Oh, and it takes a lot of time which means it costs a lot of money.

Doctors spend a lot of time and money going to school to become experts on the human body – that’s who I want taking care of me. Unfortunately, they are burdened by a system that requires they write specific phrases, terms, and codes just to get paid essentially becoming experts in understanding a set of reimbursement business rules – that’s not who I want taking care of me. Healthcare is an industry that’s core infrastructure, its backbone of information centered on diagnosis, procedure, and other treatment and care delivery codes, is broken. Why? Because all of that information is currently written down – not electronic!

I’m prepared to help fix a broken system. I have personally seen over 100 different ways for a physician to write down their observation after a routine visit with a patient. This includes the phrasing of the words, penmanship/legibility, abbreviations (only officially “accepted” abbreviations though), and interpretation.  The same thing goes for an appendectomy, blood work, an MRI, and an annual physical. This is unacceptable. The important information that a physician records must be entered as discrete data elements directly into a computer. This means that each piece of data has its own field – sorry circulating nurses who love free-text “case notes” sections at the end of surgery – and the time of free text and narrative documentation is over. Do you know how much time and money can be saved by avoiding the endless paper chasing and manual chart abstraction? Me either, but I know it’s a lot!

How do you fix it? I’m not going to lie and tell you it’s easy. Governance helps. You can guarantee that surgeons, anesthesiologists, hospitalists, specialists and the rest will all have their needs and comforts…and opinions. “If you want to perform surgery at this facility you need to document your information discretely, electronically, consistently and in a timely fashion.” Physicians are used to writing stuff down, its familiar, its comfortable, it’s home cooking. In order to change that comfortable behavior you must emphasize the benefits:  they will spend less time documenting, they will have faster clinical decision support, they will have automated and timely reporting capabilities, they will have near real time feedback on their performance, benchmarks against best standards, and opportunities for improvement. Doctors can appreciate an investment in an evidence-based approach. In order to automate the collection, reporting, and analysis of the mountain of information collected every day, on every patient, in every part of the hospital, it must be entered discretely. That or you waste more time and money than your competitor who just went all electronic. Do you really want to control costs and get paid faster?  Stop using paper and join the 21st century!

4 thoughts on “Analyzing Clinical Documentation Requires Discrete Data

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