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A thoughtful (and successful) approach to clinical documentation

The physician’s note serves many masters, and organizations are getting creative about improving clinician experience with documentation. One approach stands out from the crowd: Phoenix Children’s Hospital Chief Medical Information Officer Vinay Vaidya, M.D., successfully led an IT-clinical collaborative effort to improve clinical documentation.

It involved moving complex ambulatory clinics from paper records to a sophisticated electronic system with templates that help clinicians demonstrate the quality of care they provide. As reported in a recent Health Leaders Media article, the initiative saved $1 million in annual transcription costs, improved the clinician experience and provides the right tools for quality-based population health management.

IT-Clinical “to-and-fro exchange” is key to success

We physicians can be picky about our notes – what we capture, how they look and the process we use to complete them. New requirements from regulators, payers or lawyers just add new layers on top of the clinical pieces we need. Our frustration builds when notes are “bloated” with additional detail, or if we have to fight too hard to keep documentation practices that are meaningful to us.

Dr. Vaidya understood that frustration, and did a lot of homework before embarking on a clinical documentation improvement project. He took the time to understand clinical best practices, evidence-based guidelines and regulatory requirements. He armed himself with data before meeting with physicians, and then dove into the specific needs of specialties across the 30 divisions of its ambulatory clinics to develop disease-specific documentation templates.

For example, the Health Leaders Media article focuses on juvenile idiopathic arthritis (JIA), a complex condition to document. One rheumatologist is quoted as saying, “No EMR is going to be able to handle this, because in rheumatology we deal with 71 joints and it’s going to be clutter.”

But Phoenix Children’s Hospital’s collaborative approach meant that IT and clinicians were “joined at the hip” to create a better solution. Clinicians know the disease; IT folks know what’s technically possible. With multiple “to-and-fro exchanges,” the template becomes something productive for both teams.

There are no shortcuts

Phoenix Children’s Hospital gives us a great example of what we can accomplish when IT and clinical sides work together. Because the organization uses an open Allscripts Sunrise™ platform, it had the foundation it needed to choose the third-party technologies that worked best for its teams.

Having the right tools can make all the difference in clinician experience. Quoting Dr. Vaidya from the article:

We’ve heard a lot of pushback about the EHR … Yes, if you want to capture all the measures, if you want to do a good job, there are no shortcuts. But even with that we have shown that this is not increasing your time and effort. Within the clinic visit, you can really take your disease management to a new level given the right tools. … I think that with the right tools for documentation, with the right EHR in place, with the right governance and collaboration, we really can achieve what we set out to say what EMRs can do.

Kudos to the team at Phoenix Children’s Hospital for a job well done.

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