The adoption of digital health records have proven to improve both the quality of records and care delivered to patients. As more and more hospitals and health systems adopt digital health records, one can look at leveraging a well trained virtual workforce supported by technology and automation to help reduce the burden of clinical documentation.
Shahid Akhter, editor, ETHealthworld, spoke to Senior Vice President, Operations, IKS Care & Coding, to find out more about the existing challenges and latest advancements in the creation of digital health records.
How does clinical documentation affect the support and management of health services?
There are 5 critical aspects that are enhanced with the use of correct clinical documentation.
Comprehensiveness: Clinical documentation allows the healthcare professionals to capture details of the patients’ medical condition, history, allergies, and any other relevant facts within the electronic records. This documentation therefore becomes a permanent part of the patient’s medical record.
Safety: Clinical documentation improves the patient's safety by being available at any time to any healthcare professional, clinician or physician through the patient’s care journey. These records are also accessible through different care settings or geographies.
Timeliness: Access to a patient's comprehensive medical history also enhances the timeliness of care delivery. Additionally it improves compliance, and helps caregivers with time sensitive interventions.
Cost Effectiveness: A record that is available at the click of a button saves significant time and effort as opposed to having to pour over paper records and filling out manual documentation each time the patient visits a healthcare professional.
Analytics: One of the biggest advantages of clinical documentation is the support that it provides for data analysis and insights into the patient's medical history. The data can be leveraged to drive predictive analytics using genetic, lifestyle and social circumstances that can enable preventive as well as hyper-personalized care.
What is the main focus of clinical documentation improvement?
The main focus of clinical documentation is to comprehensively capture pertinent medical information about the patient at the time of visit or admission and follow up visits. This is an established practice in the western countries and helps healthcare professionals understand the patient's existing and prevalent health issues, medication history, reports etc. In India this practice is at a very nascent stage, where there are only a handful of large health systems and states that that have mandated the use of these electronic health records.
Challenges and ways to improve clinical documentation
Clinical documentation continues to be a significant challenge for healthcare professionals and organizations as they take significant time out of direct patient care for physicians and clinicians. Such detailed clinical documentation needs additional hours from medical professionals to complete. There are also chances of errors at the time of creating these documents. Studies show that the administrative burden that clinical documentation creates for the physicians and clinical staff can lead to burnout.
The adoption of digital health records have proven to improve both the quality of records and care delivered to patients. As more and more hospitals and health systems adopt digital health records, one can look at leveraging a well trained virtual workforce supported by technology and automation to help reduce the burden of clinical documentation.
What role does IKS Health play in Clinical Documentation Improvement for patient care?
IKS health is a provider enablement platform that is driving healthcare from digitization to digitalization, eventually to digital transformation. We work with Provider Enterprises in the US to enable better, safer and more efficient delivery of care to their patients. This is achieved through various solutions for the physicians and clinicians across the patient journey to unburden them from the administrative chores. And that is our core focus, which includes a basic philosophy that we operate with - If it doesn’t have to be done by a Physician, then it shouldn’t & If it doesn’t have to be done in person, then it shouldn’t. The healthcare industry is looking at technology solutions to find answers for physician burnout, patient access and the increasing cost of care. The advent of new and emerging technology that can pave a way to mitigate some of these challenges is the credence that the healthcare organizations are looking towards. IKS Health is capable of delivering these solutions and enabling this transformative journey towards improving patient care delivery.
