Can Clinicians Be ‘Nudged’ to Take Better Notes?
By Eric Wicklund
Documentation is often called a burden; but it’s also a necessity. An incorrect or incomplete medical record can negatively affect everything from charge capture to clinical outcomes.
Intermountain Health is hoping that technology can help ease that cumbersome task for care teams and improve efficiency in a new partnership with Solventum, whose CDI platform is now integrated with the EHR. In the process, they might also help clinicians become better caregivers.
According to Kory Anderson, MD, CHCQM, PHYADV, FACP, the health system’s Medical Director of Inpatient Care and Clinical Documentation Integrity, leadership wanted to bring a more proactive approach to documenting, with technology that prompts – or nudges — the care team to ask questions and consider options at the point of care, rather than later on.
“For example, when you have a team of nurses who are looking at charts while patients are in the hospital, or shortly after discharge, to see if there’s a missed documentation opportunity,” he says. “They [may] then send a query … to a provider to get further clarification, to improve specificity in a document or in a diagnosis, or add a diagnosis or validate that it’s clinically present or relevant.”
“What we’re looking at really is not to completely dismantle that type of workflow,” Anderson adds, “but rather, is there an ability to also get upstream of some of that documentation so that it’s happening more at the elbow, as the provider is doing their notes, to improve both the upfront accuracy and the storytelling.”
And that’s where technology may be most useful. Clinicians often list documentation demands as one of the prime drivers of stress and burnout, with plenty of anecdotes around finishing the patient’s medical record at home, in pajamas, after dinner, instead of watching TV or playing with the kids. They may see it as a necessary task that must be completed rather than an integral part of clinical care.
The value of queries
Anderson says a CDI platform not only smooths out the process, allowing clinicians to create a more detailed and complete patient summary right after the event, but it can also help clinicians to become better at documenting by giving them advice on what they may be missing.
“Hey, we see you’ve documented this. Is there an opportunity for anything more?” he says of the platform. “And you kind of leave it up to the provider to answer whether there is or there isn’t. Maybe you provide some options of what could be documented more.”
“It’s a very fine line of giving the doctors tools to be prompted when there’s an opportunity to capture a little bit more specificity or a little bit more clarity, but not telling them what to do or telling them what to say because that does sort of rub up against potentially some compliance concerns,” Anderson says.
Anderson and his staff collect data on how often each clinician is queried, and how often they respond to those nudges. A clinician who gradually reduces the number of queries might be improving documentation to the point that less interventions are needed.
They also look for nudges that aren’t addressed. Is the clinician ignoring advice? Or is the query not relevant, and therefore intrusive? And what care pathways or conditions result in the most queries? Are clinicians having a difficult time documenting certain conditions or treatments and need more guidance on what to do?
What improved documentation means
From these questions, Anderson says they’ll track the ROI in the CDI platform in terms of reduced documentation time, particularly after hours, reduced time in the EHR, as well as improvements in coding and charge capture that lead to specificity in the final claim. And they’ll look for more complete and accurate patient histories that eventually will lead to better clinical outcomes.
That, he says, will help Intermountain fine-tune its risk management and valued-based care programs.
Anderson is quick to point out that healthcare organizations have to lay the foundation for an effective CDI program, beginning with the IT department. Identifying what resources you have and what you need goes a long way toward sustainability.
“You need to have good internal people that understand data, that understand analytics, that understand the technology,” he says. “If you are a small organization and don’t have that that resource or infrastructure in place. You may get data, but it may not actually be good data, and you don’t have anybody there to help you poke holes in it and question the way maybe we do or some other bigger organizations do.”
One area where this platform could show real value, Anderson says, is in end-of-life care.
Clinicians are often unprepared to fully document when patients and their families are given such a devastating diagnosis, and in many cases key palliative care steps are missed. Anderson says a CDI program that assists clinicians in real-time, offering nudges on steps of care and recommended actions, could improve the process for both clinicians and their patients.
“If we can get upstream with some of the documentation accuracy with our providers, that’s less downstream documentation queries or interruptions or questions that we have to then send to them,” he notes.
Eric Wicklund is the Associate Content Manager and Senior Editor for Innovation and Technology at HealthLeaders.