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The rollout of the Affordable Care Act, new initiatives by providers and payers, advances in technology and increasing patient expectations are altering the healthcare landscape in significant ways.  These changes have the potential to improve outcomes and contain costs; they also have profound implications for what clinical information is captured and how it is documented.

To better understand the impact of these changes, the Health Business Group recently released Clinical Documentation Trends in the US, 2013-2016, a study sponsored by Nuance Communications, Inc., which presents data and discussion on how hospitals and physician practices are generating and using clinical documentation.  The following are some of the major trends that will directly impact the future of clinical documentation:

  • Growth of Integrated Delivery Networks (IDNs). Hospital systems are increasingly acquiring and affiliating with other hospitals, physician practices, and sub-acute facilities to offer a wider range of services, broaden geographic coverage, and increase their leverage in negotiations with payers.  IDNs are going beyond re-branding to deepen the level of clinical integration across the continuum of care.
  • Implementation and optimization of electronic health records (EHRs). The ARRA/HITECH Act has spurred a massive investment in EHRs by hospitals and physician practices.  As providers strive to attain the higher stages of Meaningful Use, they are increasingly deploying EHRs for clinical documentation –even when doing so causes friction with physicians who are required to use unfamiliar and sometimes inefficient interfaces.
  • The emergence of Big Data.  The digitization of information, massive gains in computational power and ability to meld disparate data sources are enabling providers, payers and others to generate increasingly powerful insights on individual patients and larger populations to improve care and contain costs.
  • The transition from ICD-9 to ICD-10 for coding.  ICD-10 will bring a massive increase in the number of codes along with changes in structure and concept.  The shift will be disruptive for documentation but carries the potential to extract much richer and more specific information.

These trends will bring substantial changes. However, there are practical steps provider organizations can take to anticipate and capitalize on the coming shifts:

  • Develop an enterprise-wide documentation strategy.  True clinical integration across the continuum of inpatient, sub-acute, and outpatient care demands an overarching clinical documentation strategy.  IDNs that adopt a unified strategy will be well positioned to manage population health, improve clinical quality and participate in risk-sharing opportunities such as Accountable Care Organizations (ACOs).
  • Use technology to enhance productivity and improve value added.  Back-end speech recognition, Clinical Language Understanding (CLU) and Natural Language Processing (NLP) increase productivity and generate insights.  Tools such as computer-assisted physician documentation, which prompt for specific details about patient encounters, help ensure more accurate and complete documentation.
  • Make strategic use of outsourcing for transcription.  As transcription volumes change, sophisticated providers are shifting the transcription function to outsourced Medical Transcription Service Organization (MTSOs). Larger MTSOs possess economies of scale and advanced technologies that enable providers to reduce costs while improving quality and decreasing turnaround times.
  • Plan for a clinical documentation environment that has a mix of EHR-based, dictated and transcribed documents.  Clinical documentation is optimized when clinicians can choose the appropriate tool to fit the task and setting.  One-size-fits-all models sound simple and elegant in theory but don’t work well in practice.

Amid all of these policies, changes and tactics, it is important to stay focused on the long-term goal: enabling clinicians to create stronger documentation that accurately reflects the patient populations they serve.  Provider organizations that generate high quality clinical documentation can tailor their programs and services to meet the needs of the community.


About David E. Williams

This was a contributed post by David E. Williams, president of Health Business Group. To see more content like this, visit the Healthcare section of our blog.