This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Tammy Combs RN, MSN, CDIP, CCS, CCDS
I recently had an opportunity to go on a medical humanitarian mission trip that gave me a new perspective on the relationship between data and patient care. Even though the trip was short—just one week—it left me amazed at the transfer of information that took place among the medical team.
During this week, we ran two outpatient clinics and saw over 1,500 patients. As I observed the high volume of patients moving through the clinic, I found myself contemplating the process in which we see patients in the US. In an 2014 Washington Post article, Lenny Bernstein discussed a 2013 survey by the American Academy of Family Physicians that found the average primary care physician sees about 19 patients per day. The physicians at these mission clinics averaged around 42 patients per day. And while I expected to find them weighed down by this heavy load of encounters, at the end of the day they had a tremendous feeling of accomplishment and satisfaction.
At the mission clinic, the care delivery team’s focus was first and foremost on the patient. This struck me as different than the way patient encounters are approached in the US facilities I’m familiar with, where there is more upfront focus on information about the patient. Of course, patient information in the mission clinics was still important—and this data was used to diagnose and develop a treatment plan. However, physicians were not interrupted numerous times of the day to correct documentation, clarify orders, or sign off on documentation. All of that information was still needed, but it was included on an easy-to-fill-out form that did not include a lot of extraneous information. In addition, everyone was in close proximity to each other so if a question came up it was quickly addressed.
In the US, we have many options when it comes to the collection of information—some that could even be considered “high-tech”—but I wonder if the proliferation of these different avenues for information transfer and communication sometimes make it easier to bring obscurity to the path of streamlined communication. How can we find a way to obtain the information without diverting more clinician energy and taking time away from the patient? After all, the foundation of healthcare is the patient and the care provided to them.
As Herbert L. Fred, MD, MACP and Mark S. Scheid, PhD explain in the special report “Physician Burnout: Causes, Consequences, and (?) Cures,” there is an increase in physician burnout related to feeling they are treating the data more than the patient, a sense of powerlessness, and electronic health record (EHR) woes. They go on to explain that physicians feel they are being controlled by governmental and insurance policies that result in a loss of autonomy, moving their focus away from the patient and onto the data. For many physicians, the EHR has become a burdensome necessity, where for every hour spent on patient care they end up spending another two entering data into the computer.
The EHR was supposed to streamline and revolutionize healthcare, but for some providers it feels more like an obstacle than a tool. What if instead of spending our time focused on the information and potentially adding to the complexity of healthcare documentation, we re-center our focus on the patient with an eye toward developing processes that revolve around the needs of the physician and the patient?
Tammy Combs (firstname.lastname@example.org) is a director of HIM practice excellence at AHIMA.