Dr Richard Gain

Dr. Gain’s clinical background is 17 years of practice in family medicine. In 1995, he embarked on a career in health informatics, motivated by the goal of making clinical IT systems more useful and usable for clinicians. Meet Our Contributors

In my first post, I talked about the need to get busy clinicians to take ownership of the task of writing clinical notes in EMR systems and discussed the benefits of more fully coded forms of documentation. Today, I want to talk about how improving the quality of documentation might lead to improvements in patient care.

Any organization conducting a quality review of the documentation generated by its clinical staff is likely to find significant variations in the quantity, quality and style of notation. In light of the growing body of evidence that errors and omissions in clinical documentation are directly responsible for financial underperformance at the very least and more serious clinical incidents in the worst cases, many healthcare organizations are choosing to tackle this proactively with high-level involvement.

In the 2010 paper: “Clinical Documentation: More than a cumbersome chore”, the authors begin by describing a point of view that many clinicians will recognise: “performing clinical documentation duties … often feels like an intrusive burden that simply eats up valuable time, those precious minutes and hours that could be better spent directly interacting with patients”. They, along with many others, recognized the need for improvements in the quality of clinical documentation and undertook a major re-evaluation of the scale and nature of some of the deficiencies.

Not surprisingly, there was no simple solution; however, the multidisciplinary team conducting the study were able to identify some important guidelines that would help to bring about lasting change in behaviour. Two of their most significant conclusions were, firstly, that documentation needed to be completed pro-actively and in real-time rather than as a retrospective chore. And secondly, that technology could be used more effectively to prompt clinicians to document their notes at the point of care.

They also recognised that the documentation process, in general, needed to be more tightly integrated into existing quality improvement initiatives. By providing their nurses with the right equipment (hardware that worked at the patient’s bedside), updated policies (that clarified record-keeping expectations) and appropriate reporting tools to manage compliance, they saw dramatic results in the first month.

But the study did not only focus on costs. Proper documentation of patients’ progress during their stay in hospital led to better pain management, a reduction in pressure ulcers, and improved communication of clinical information between team members at end-of-shift hand-overs.

A team at the Pittsburgh’s Jefferson Regional Medical Center undertook a similar exercise in 2008 which they reported in their Case Study: The Rewards of Accurate Clinical Documentation. Their findings showed that by making documentation improvement an organization-wide priority and instituting the necessary changes to policies, guidelines and monitoring opportunities, they not only secured buy-in from their staff but also emphasized the need to make the documentation process concurrent to care provision, rather than retrospective.

WHO’s Guidelines for Medical Record and Clinical Documentation clearly indicate within their first guiding principle that “Information documented during or immediately after care is provided or an event has occurred is considered to be more reliable and a more accurate record of care or an event than information recorded later, based on memory.” Of course, this emphasis on contemporaneous record-keeping is only likely to be of value if the technologies used by the clinicians are capable of supporting their basic requirements –a system that is quick, intuitive and available when it is needed.

Other commentators have highlighted their own perceptions of the holy grail of clinical documentation. In an interview with Patricia Sheridan, Rita Scichilone from AHIMA, discussed the impact that new quality indicators will have on the need for improved documentation. “It will be paramount that quality measures are captured as part of the day-to-day clinical workflow process, and incorporating technology tools to automate the process will make it more efficient,” Scichilone said.

Patricia Sheridan surmised that “The ability to take a physician’s spoken word and translate it into meaningful clinical documentation and data that can be queried will completely transform the way we collect, code, use and report clinical data.”

This richness of this data will undoubtedly play an important role in more sophisticated decisions about reimbursement for provision of care, but the information about quality indicators derived from this data will probably have the most significant direct impact on clinicians.

The WHO Clinical Documentation Guidelines list six purposes of professional documentation, at least three of which (Accountability, Legislative Requirements and Quality Improvement) have direct personal implications for individual care providers. The first two are the stick, whilst the third one is the carrot. Over time, personal evaluation of clinical data derived from aggregated information will allow clinicians to review the evidence of their own performance in relation to their peers. The evaluation of professional practice that is required of a modern health provider as part of the quality assurance process is never an easy or comfortable task, but the relentless push towards providing a better service can only be a good thing for patients.

So where does Clinithink technology fit it into this organisation-led drive for improved quality of clinical documentation? The evidence is all leading to the conclusion that high quality medical records need both to have high data content and be richly descriptive and be completed promptly. Form-based data entry tools can be useful for collecting certain specific data elements, but in general clinicians much prefer the freedom of expressivity that free text notation allows.

Clinithink’s CLiX technology has the power to extract meaningful clinical data from free text in real time, prompting the clinician to select from the suggested SNOMED expressions, those which most accurately reflect the intended meaning of the record. This disambiguation of clinical meaning is a much more natural and less arduous process than expecting clinicians to pick the best billing codes and helps to preserve the individuality and character of the record. The author of the note is best placed to provide this clarification and Clinithink technology alleviates the pain of achieving high quality and data rich clinical notation.

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