Healthcare documentation has come a long way. A continuous stream of technological advancement and automation has generated significant gains in efficiency while increasing the quality of care through improved access to vital patient information. The future looks bright indeed, as incremental improvements in technology promise to confer additional benefits. Many health care providers are embracing new versions of technology as quickly as they are rolled out in the hope of delivering heightened levels of patient care at a lower cost.
Nowhere are the advances in technology felt more keenly than in the healthcare documentation arena. For many years, medical records departments have been viewed as cost centers and subordinated to other seemingly more important areas of the healthcare organization. As a consequence, healthcare documentation has historically received neither the glamour nor the funding that other front office and patient care activities have enjoyed. Over the past few decades, however, the balance of power has begun to shift. Healthcare documentation is now rightly seen as one of the keys to profitability and a catalyst for industry growth.
New talent and resources are beginning to flow into this area breathing new life and vitality into what was once an afterthought in most healthcare organizations. Leading the charge is a new breed of profit minded executives set on transforming the healthcare model. As the industry ushers in a new era of efficiency and profitability, decision making executives would do well to remain aware of some of the significant risks of an overly ambitious technology adoption timeline. For instance:
Underdocumentation
The risk of underdocumentation has the potential of increasing dramatically with new electronic medical record (EMR) protocols. That EMR technology promises to exponentially increase efficiency in some aspects of care – primarily by decreasing administrative workload and increasing the speed of information flow – is not in dispute.
However, it should be recognized that the rapid adoption of this technology in its current form has the potential to create down- stream issues with patient care as a result of improper or inadequate documentation. EMR threatens to increase costs as inadequately documented assessments and activities are reworked. Patient care may also be compromised as diagnoses are delayed due to lack of complete information flow.
Underexamination
EMR’s may steer physicians to point and click their way through a few standard procedures, potentially ignoring less obvious, non-charted options.
Undervaluing the traditional role of the physician
As technology asserts itself with fits and starts into the patient care process, there is a real risk that the transition from physician directed outcomes to technology driven outcomes will be too abrupt, again compromising patient care. Additionally, recent studies suggest that the physicians spend about 9 times longer entering an equivalent amount of information via EMR and EHR than with traditional dictation based narratives. Time is money, and physician resources are far too costly to be assigning tasks better handled by non-physician professionals.
Chronic under reporting
Pushing physicians in a direction of drastically less documentation when the trend has been toward greater documentation of patient care for the past several decades is at best imprudent and at worst reckless. While some efficiency in healthcare documentation may be good and necessary, it is simply unrealistic to expect a physician to render what has historically been a multi-page detailed medical record document with a few clicks of a mouse.
Undervaluing the role of the medical transcriptionist and medical record technician in the records process
Speech recognition has made some significant strides in recent years and now plays an increasingly prominent role in the healthcare documentation process. However, it has still not proven to be as effective as a seasoned transcriptionist in rendering a dependable output – particularly when it comes to some of the more complex documentation tasks. There are simply too many variables that require human intervention to achieve consistently accurate and completely automated documentation with today’s technology. While it seems clear that the role of the traditional medical transcriptionist will be forever transformed by new advances in technology, there will likely always be a role, and I trust, an increasingly important role, for the professional medical records technician.
Conclusion
As technology continues its steady march, there is no doubt that it will continue to encroach on traditional methodologies and bring a new and important measure of efficiency and profitability to the healthcare industry – benefiting patients and practitioners alike. Those organizations that are careful and thoughtful in their implementation strategies will tend to have smoother transitions and will likely manage their risk more successfully than their more zealous counterparts.