Game Changers - Documentation

Leading practices have realized that clinical documentation is a key strategy in a Game Changing practice environment where efficiency and productivity are becoming ever more critical and service justification essential. Why? Because documentation takes time away from service provision and revenue production; and third party payers are always looking for ways to reject payment.  

There are five primary reasons for clinical documentation.

1.  For  continuity  and  quality  of  care  –  Clinicians  forget  things  and  sometimes need  to  have  someone  else  provide care. 
2. For  reimbursement  –  Payers  want  to know  that  services  are needed, appropriate, beneficial,and delivered. 
3. For medical‐legal  liability – Occasionally things  go  wrong  and  need  to  be investigated.  Truth  is,  too  much information  can  be  as  harmful  as  too little and therapist malpractice rates are a testament to low risk.  
4.  For  research  –  Learning is  important. But fact is that very few practices or clinicians are actively involved in clinical research, so many practices track far more information than they gain value from. 
5. For marketing – optimized documentation tells a story of efficiency and effectiveness that can be used strategically for competitive advantage and growth.

 Documentation is another Goldilocks Issue – not too big, not too small, not too hard, and certainly not a bear! It needs to be kept “just right”! Too big wastes time, while too small compromises clinical care and reimbursement. “Just right” adds value!

So what does “just right” look like?

It begins with three simple rules:

1. Do all and only what needs to be done. 
2. Do it once and do it right.
3. Do it fast, cheap, and accurate.   

Then certain key strategies are leveraged…

1. A standardized minimum data set captures all and only what information is needed.
2. Exception reporting is leveraged to reduce volume and simplify content
3. Workflow offloads tasks and simplifies administration and management
4. Computerization is deployed strategically, not as an end in itself - yes there are things that should not be computerized
5. Data is interpreted and not just dumped on recipients
6. Reports are audience specific and tailored to their need to know
7. Narratives are replaced by information mapping
8. Repetitive tasks, content and analysis  are templated and automated
9. Accountability is built in - think progress against stated discharge criteria - not just goals
10. Documentation is completed in real-time but never at the expense of patient interaction

Inefficient documentation is common, even where computerization has been implemented. It wastes valuable resources and undermines service capacity. Good documentation systems add multidimensional value.

Optimized documentation is more a matter of strategy than software.  So it’s no surprise that so many (most) practices are disappointed with their software investments.  

The solution is revolution not evolution.  

Leading practices recognize the need to do more for less and that in matters of documentation less is more! When done well, the cost of documentation can be reduced by half or more while revenue is improved. No wonder its caught the attention of leading practices.

I have strong opinions on documentation. It comes from working on clinical documentation systems for over 20 year. I've had the privilege to design and implemented several proprietary computerized clinical documentation systems. Systems that were built from the bottom up with productivity built in. The opportunities came because my clients found they were unable to find commercial systems that provided the functionality, features, and efficiency they were seeking.  

Commercial clinical documentation systems are designed to allow customers unlimited customization - the only limit is what the client can afford to spend for customization - usually customization only perpetuates inefficiency and unnecessary expense. There are are better ways. What I've shared here is the tip of the iceberg.

Optimized clinical documentation is a dependable Game Changer that can yield a positive return on investment every day. Documentation is one game that most practices need to change. Its not about computerizing old habits but rather about innovating better and more efficient habits. The former is equivalent to paving wondering cow paths - that latter is like building a multi-lane expressway between point A and point B.


Is it time to get strategic? Is it time to reduce cost and increase profitability with every patient encounter? Is it time to realize a built in competitive advantage? Now you've got the idea!


Next Post - Profit Planning.

All The Best!

Bob

© Copyright 2010

Performance Builders