The heart of the provider/patient interaction, beyond the visit itself, is the provider’s documentation.  For many years, our charts were folders that moved around with the provider or his team containing hand written notes, old scripts, and eventually neatly typed dictation. The ‘chart’ is a whole new world now and the challenge to healthcare systems and the IT teams who support them are to make documentation work for the provider. For every EHR there are multiple ways to document a clinical visit; point and click, macros or ‘smart phrases’, free typing, dictation interfacing, voice recognition, scribes, etc.  Despite the many efforts by the EHR industry to enhance all of these options many providers still find the process onerous and time consuming. To go live with the perfect solution and combination is no longer realistic; the post go live phase of optimization is ideal for addressing this area. Is optimization through customization the key to accurate EHR clinical documentation?

Many projects go live using some of the basic documentation provided with the purchase and very little customization. Customization can be part of the solution but only if the optimization efforts for documentation are carefully approached.  Customization is not the Holy Grail, however if done well and with clear intention, can pave the way to more successful optimization of EHR documentation.  Here are some initial guidelines to use for successful customization of EHR documentation as part of your optimization efforts.

  • Enlist a Physician Champion and train them well – Providers will resonate well with their own team members, especially if that team member is already a formal or informal leader.  The key to success is for the physician champion to fully understand the scope of customization, the depth of time it takes to create templates or forms as well as the larger impact in the future.
  • Drive change with consensus and flexibility – Although it can be hard to have everyone agree on exact language that is produced in point and click documentation, by asking for some level of consensus, organizations are able to develop standardization that assists with coding and appropriate service billing. Flexibility is key in knowing when to concede and offer options, variations to meet certain circumstances. A Physician Champion is critical in these discussions.
  • Managing Change requests – Have a process and forum for requests to be submitted, vetted and implemented into the EHR.  Users need to know their requests are valid and understand why they cannot be met or in what timeline they expect to see changes.  Optimization needs to balance the requests of users with actual functionality and the realities of budget and timeline.

Unfortunately not everyone can be made happy at all times in an EHR world, but that was also the case in the ‘paper’ world.  Providers wanted to use computers and some did not; however EHRs are here to stay and the ease of use will increase if those of us who support them make documentation successful.  Optimization may not fix all the pain points but it can create a process and pathway for success in this vital area of the EHR.