How to Improve Efficiency of EHR Documentation

It is well known that EHR documentation is a major contributor to physician burnout in healthcare. Since EHR systems became widespread in the medical field about a decade ago, healthcare providers and industry experts have worked hard to improve these systems and find new ways to lessen their negative impact.

In a perfect scenario, EHR documentation would improve patient health outcomes and support better reimbursement for clinicians. However, in practice, it can be challenging to see a direct return on the time spent on documentation. Striking the right balance between high-quality documentation and efficiency has been a significant struggle for healthcare professionals but can be improved by implementing some simple strategies. Read the full article to understand the importance of EHR documentation and how to implement it: 

Tips for Efficient EHR Documentation 

Efficient EHR documentation is essential for improving patient care by ensuring accurate and timely information is available to healthcare providers. It helps streamline clinical workflows, reducing administrative burden and saving time for clinicians. Proper documentation also supports better reimbursement by meeting coding and billing requirements. Additionally, it enhances communication among care teams, leading to more coordinated and effective patient treatment. Here are six tips for EHR documentation that clinicians can use to improve patient outcomes, manage their documentation, reduce burnout, and enhance reimbursement.

Prefer Quality Over Quantity

For years, it was assumed that effective EHR documentation meant recording as much information as possible, with the belief that this would lead to better patient care, higher reimbursement rates, and protection against malpractice lawsuits.

In reality, the quality of the notes is far more crucial than the amount of information documented. Adding excessive irrelevant details can clutter a patient's record, making it harder for healthcare providers to find essential information when needed. This doesn’t mean that documentation should be vague or incomplete; on the contrary, medical coding rules, such as those in ICD-10, require thorough documentation. The key is to focus on specific details that matter. Detailed clinical documentation can lead to improved reimbursement rates for clinicians.

Bring Templates in Your Documentation

A significant challenge in the current documentation system is that creating highly detailed, ICD-10 compliant notes takes a lot of time. A slight dip in documentation quality can lead to a higher risk of malpractice claims or EHR audits.

This is where EHR documentation templates come in. They can help streamline the process during patient visits by guiding the clinician through the patient’s medical and procedural history, clinical assessment, and care plan. These templates can be tailored to include all necessary ICD-10 information in a way that is both comprehensive and efficient.

Templates should be designed to collect both structured data for medical coding and free-text fields for additional notes. It is important that these templates are specific to the patient's visit type and healthcare specialty, as the nature of the encounter varies depending on the care provided. Providers should also regularly review their templates with their teams to ensure they are working optimally.

Clinicians must also be mindful when using templates and make sure they are accurately updating any changes in the patient’s health, such as lifestyle habits, ongoing treatments, or medications.

Hire a Nurse Informaticist

For providers who find it challenging to collaborate with EHR representatives in optimizing workflows, a nurse informaticist can be an important resource. Nurse informaticists focus on workflow management, nursing science, data analysis, and the integration of technology. Many healthcare providers hire nurse informaticists to improve EHR documentation practices.

Nurse informaticists play a key role as both users of EHR systems and experts in technical design and data analysis. They are in a unique position to enhance EHR systems in ways that improve quality and workflows to meet the needs of clinical staff. Studies have shown that involving nurse informaticists in the process of refining EHR documentation can improve efficiency, productivity, and coordination among different care teams.

Some healthcare organizations opt to hire nurse informaticists on a contract basis, which can be a more affordable way to optimize EHR processes without making a long-term commitment.

Get Onboard the EHR Vendors

Though well-designed templates can improve documentation efficiency, it’s also important for providers to work closely with EHR vendors to maximize the effectiveness of the software. Vendor representatives can help customize workflows to fit the specific needs of different medical specialties, which can be especially beneficial for healthcare organizations with larger teams.

Specialty-specific workflows and templates help streamline documentation and ensure that clinicians are up-to-date with the latest software improvements and changes. By collaborating with vendors, clinicians can optimize their systems to improve documentation efficiency and maintain high-quality care standards.

Give Patients Access to EHRs 

While using templates and optimizing workflows can enhance documentation speed, clinicians must ensure that they are not blindly transferring outdated PHI into every note. For example, self-reported details like smoking status can change between visits, so it is essential to update these data points as needed.

One way to address this is by giving patients access to their electronic health records so they can update or confirm any non-static information. This practice has been mandated by the federal government under the 21st Century Cures Act, which went into effect in April 2021. It requires healthcare providers to make notes related to consultations, medical history, procedures, and progress available to patients.

Giving patients access to their records can not only foster better understanding and transparency but also ensure that both patients and providers are on the same page about the patient's health status. With future innovations, appointment management tools like EZ Arrival might allow patients to confirm health information directly, which could streamline the documentation process while improving outcomes and patient satisfaction.

Document During the Visit

It’s widely accepted that documenting a patient encounter during the visit is more efficient than relying on memory after the fact. However, documenting in real time can be challenging for clinicians, especially without assistance. To improve this, healthcare providers might consider investing in solutions such as AI medical scribes, transcription services, or dictation tools to capture information during the visit. Another option is using AI-powered scribes that automatically record EHR details.

While each solution comes with its own set of pros and cons, they can all help improve documentation efficiency. These tools can be particularly helpful for providers struggling to keep up with administrative work while maintaining quality patient care.