With the pressures being placed on healthcare organizations and providers — ranging from participation in the EHR Incentive Programs to compliance with ICD-10 — it’s easy for the former to become overwhelmed. However, this feeling could prevent hospitals and physicians from taking things one step at a time and prioritizing appropriately.
“It’s so easy to get overwhelmed,” Lou Ann Widemann, MS, RHIA, FHIMA, CDIP, CPEHR, Director of Practice Excellence at AHIMA, told EHRintelligence before the organization’s 2013 Clinical Documentation Improvement (CDI) Summit in Washington, DC. “You have to step back and say, ‘What’s my immediate need right now?’ That sometimes is a very personal decision for the physician or the hospital. It seems to be that people are trying to prioritize based on implementation or due dates.”
For eligible hospitals and professionals staring down meaningful use and ICD-10, success going forward generally hinges on their efforts to improve their clinical documentation. And although the adoption of EHR systems helps to automate this documentation, according to Widemann it can do more harm than good if not approached correctly:
People assume that the electronic health record is going to solve their documentation problems. And it doesn’t. If you have poor documentation habits now and you automate the same exact process, you then have a poor electronic process. There are some opportunities to look at what the EHR can do for you: you’ve got drop-down menus; you’ve got templates you can use; you’ve got checkboxes. Obviously, you have a learning curve to get used to those things, but once you do you have opportunities to make it really easier to document and paint a clearer picture.
Whereas the transition from Stage 1 to Stage 2 Meaningful Use involves capturing similar measures and levels of specificity, the update to ICD-10 represents a dramatic shift in how clinicians document care and therefore requires healthcare organizations and providers to be more careful in deciding what the right approach is to achieving compliance with the latter.
“Start looking at your practice, what you do and see, and then think about how ICD-10 will affect that,” advises Widemann. “Don’t try to do it all. Try to focus on the majority of the patients you see. If you’re an orthopedic surgeon, then focus on those changes. If you’re a pediatrician and you see a lot of asthma, focus on that. It’s all about focus. From a physician’s standpoint, if 50 percent of your patients have asthma, then I would focus on that.”
Once providers have mastered those aspects of ICD-10 common to their practice, says Widemann, they can then move on to general things and add to their knowledge base incrementally. And accompanying this incremental approach should be making use of the resources already available to healthcare organizations and providers.
Look at what other people are doing and think about how you can use those things in your practice,” Widemann recommends. “Don’t reinvent the wheel. There are tons of resources.”
As the effort to improve clinical documentation reveals, how physicians and other clinicians document their care is a work in process. Like art, it takes time to refine clinical documentation to their point where it presents a clear picture of quality care.
“Documentation is not taught in medical school — nobody teaches anybody how to document — so this whole process and concept of painting the accurate picture is kind of new. You would think that it’s been around for years, but it really hasn’t. The focus on it has changed,” observes Widemann. Source
