As physicians, we are trained to keep a close eye on things – monitor slow-progressing conditions, make split-second decisions – but always in the context of ensuring the best possible outcomes for our patients. So, when electronic health records (EHRs) were introduced and compliance-related initiatives like ICD-10 announced, we grew frustrated with the daunting focus on IT integrations and documentation demands – two things that can deter us from focusing on patient care but that are critical nonetheless in the evolution of our healthcare system.

Still, what many have forgotten is that one of our key jobs as physicians is to capture our patients’ stories so as to ensure that information is available for future care episodes. While technology adoption and compliance requirements have placed initial roadblocks in our endeavor to treat patients, they’ve also opened our eyes to the type of intelligent care a digital healthcare system will offer over time. If banking could handle such a transition, why not healthcare, right?

What we, as physicians, are losing sight of is that by taking the time to properly tell our patients’ stories we are protecting their well-being. Accurate, specific clinical documentation is a pre-requisite for high-quality patient care. Clinical documentation quality impacts those you look after, and aligns directly with your own reputation and that of your institution. In other words, it carries a whole heck of a lot of weight.

As we transition to value-based care, increased emphasis is being placed on the capture and sharing of clinical data. As a result, educating physicians and arming them with tools to streamline clinical documentation has become a focal point for healthcare institutions who realize that long-term viability depends on their physicians’ ability to leverage technology to provide quality, cost-effective patient care.

So what should healthcare institutions do to ensure clinical documentation best practices while also enhancing the MD experience? The Advisory Board Company suggests the following:

  1. Physicians don’t want to become data entry clerks, so provide dynamic templates and order sets, in addition to speech recognition software with natural language processing (NLP).
  2. Physicians worry that documentation that is visible to patients will lead to misunderstandings, questions and potential lawsuits. Using new documentation standards as a teaching opportunity for patients can help increase their involvement in their own care, as well as ensure their health narratives are correctly captured.
  3. Physicians feel that ICD-10 is a waste of time that places constraints on how medicine is practiced. The transition to ICD-10 is a fundamental enabler of evidence-based medicine. Tools such as computer-assisted coding (CAC) are resources designed to automate processes and improve coding efficiency and accuracy.

Implementing processes and integrating technology that maximize physicians’ time, keeping them in front of their patients and away from their desks, is the key to long-term success for healthcare providers – and will also go a long way toward ensuring physicians’ overall satisfaction.

To learn more about how technology can enhance your clinical documentation program and physician satisfaction, check out this webinar on August 15 at 1:00 p.m. (ET).


Dr. Paul Weygandt

About Dr. Paul Weygandt

This was a contributed post by Paul Weygandt. He has developed specialized approaches to physician documentation, assisting physician leaders in communicating the importance of accurate, legally-compliant clinical documentation. Paul attended the University of Cincinnati College of Medicine and the University of Missouri-Columbia School of Law. Paul has boy/girl twins – both of whom are physicians – and a daughter who is a business executive. He and his wife are excitedly engaged in the ongoing restoration of a 150-year-old farm. To see more content like this, visit the Healthcare section of the blog.