January 31, 2012

HIMSS12: Electronic documentation – Faster than a speeding pen applied to paper?

At HIMSS12, I plan to demonstrate a documentation solution that answers the above question with a resounding, “Yes!”

At the 2011 Cerner Health Conference, Neal Patterson issued a challenge to achieve the goal of making documenting in EHRs faster than documenting with pen and paper. Computerized physician documentation improvement is challenging. Structured documentation requires training, many clicks and visual searches for the “right” item, plus it does not “tell the story.” Pen and paper require no new training, no clicks, no searching for the right word and succinctly summarizes the story.

In the paper world, the physician has to transcribe information from various places in the chart into a summary note. This transcription is done so other care providers can read key information without having to page through the chart. Examples of this kind of documentation are the immediate post-operative note and the discharge summary. With the advent of the EHR, paper documentation tasks have often been directly translated into electronic versions. This process does not take full advantage of the system’s ability to gather information from the electronic medical record and include it in a pre-completed note without end user intervention.

Using computer scripting makes it possible to create a nearly complete immediate post-operative note with data already collected in SurgiNet, including information from the surgery scheduling process. For the discharge summary, work accomplished during the discharge process, including discharge diagnoses, discharge medication reconciliation, discharge instructions, and follow-up appointments, is gathered using smart templates to build an almost complete discharge summary. Therefore, a process that previously required double documentation, multiple clicks and typing, with an overlay of frustration, is turned into a quick process taking less time than putting a pen to paper or using voice dictation. Computer documentation also ensures regulatory compliance every time.

The return on investment includes increased physician acceptance of electronic documentation solutions, immediate availability of physician documentation, reduced HIM resources to ensure documentation compliance and reduced dictation costs.

If you would like to know more about these documentation improvement solutions, please join Dr. Zimmerman on Feb. 21 at 12:15 p.m. in the San Polo room (3506) in the Venetian Sands Expo Center for his presentation, part of the HIMSS12 Leaders & Innovators Program.

Dr. Devin Zimmerman is a practicing neurologist, CMIO, and stroke unit director at Saint Joseph Regional Medical Center in South Bend, IN. He graduated from University of Michigan Medical School and completed his neurology residency at Barnes Hospital in Saint Louis, MO. He paid his way through college working at a computer center and has maintained his love of technology throughout his career. He now has a job he loves, combining technology and medicine, so he is no longer "working."