Gone are the days of doctors’ spidery handwriting rendering patient records illegible, or surgeons on a hospital ward speaking into a dictaphone, recording findings on tape to transcribe at a later date. Clinical documents in 2016 are more likely to be in a digital format, and patients are perhaps becoming accustomed to seeing healthcare providers tapping away at a smartphone or tablet screen instead of putting pen to paper.Compiling clinical documentation is an integral part of being a healthcare provider. Good patient records should allow any healthcare professional to continue treatment from where a colleague left off.
“Ask any doctor and they’ll say the same: patient records are crucial to providing quality care. It means they can see an individual’s medical history quickly without having to order unnecessary tests that waste time and money,” says Dr Vijay Magon, managing director of CCube Solutions, a supplier of electronic document management systems. “All hospitals have the same challenge – they need to cater for huge numbers of patients cost-effectively while delivering quality care.”
Poor records can lead to patient care being adversely affected, perhaps by being under or overtreated, or because early warning signs or changes to a condition have been missed. Intisar Abdullah, director of the Health Information Management Department at King Abdulaziz Medical City in Jeddah, Saudi Arabia, believes errors creep in when clinicians use prohibited abbreviations and non-approved hospital abbreviations, or on sign-off.
“Errors often occur as most of the physicians that dictate the discharge summaries, progress notes, medical reports, history, physical etc. are junior staff, but the ones that have to sign and authenticate the documents are senior staff; the majority just sign without reading the content,” she says. “When we do the record reviews, we discover several documentation errors like incorrect procedures, not listing all patient-administered medications and so on.”
One way to reduce errors is to digitise health records, a move also credited with improvements in patient safety and a more streamlined care service. Electronic health records (EHRs) contain a patient’s medical history – including diagnoses, medications, allergies, radiology images, and laboratory and test results – and can be shared across authorised providers instantly, thus reducing time wasted locating paper records and leading to better care for patients.
“Shunting thousands of paper records around a hospital system each day just isn’t practicable,” says Magon. “Hospitals aren’t FedEx-like logistics operations. Working with paper chews up staff resources, is costly and inefficient, and doesn’t reflect how modern-day medicine works.
“Clinicians operate in multidisciplinary teams, often across multiple sites or in big buildings, and all need access to the same patient file. You just can’t do that with paper. The fundamental principle of good records management is that the right patient file should be available at the right time for the right clinician.”
Starter for 10
EHRs have made putting good patient records together easier: forms and terminology have been standardised,
key findings are more obvious to those reading the records and less irrelevant detail is recorded. But clinical documentation is much more than simply a record of a patient’s treatment; it can be used to improve patient care
by allowing data on diseases and causes of death to be collated and analysed.
The implementation of ICD-10 coding – which now standardises over 14,400 different codes for diseases, signs and symptoms, abnormal findings and complaints – has also helped improve clinical documentation. In fact, ICD-10 and clinical documentation improvement (CDI) go hand in hand, as good clinical documentation and CDI programmes have been considered a main factor in the success of ICD-10.
“CDI played a great role in ICD-10 implementation because, without completing the patient records, it would have been a very poor coding. The initiatives my hospital took to improve the quality of patient record documentation were huge, and it is an ongoing process,” says Abdullah.
ICD-10 aims to allow doctors to be more specific in their diagnosis and documentation in the hope that it will lead to better and more-targeted treatment. It also allows more-accurate comparisons of healthcare data, better tracking data, and the measurement of the quality and safety of care. In some countries, such as the US, it is used to process claims for reimbursement.
“This is a work in progress. Clinical coding based on ICD-10 is being carried out but not at the point of care,” says Magon. “Work is under way – for example, using SNOMED [the Systematized Nomenclature of Medicine] – to make it easier for clinicians to record outcomes during, or soon after, patient engagement.”
The challenge of change
Although the guidelines, conventions and rules laid out in ICD-10 are very similar to its predecessor, its implementation hasn’t been without its issues, most of them associated with cost. It has been necessary for some institutions to upgrade their software – some systems were only capable of recording three-to-five-digit-long codes, but ICD-10, they can use up to seven digits, for example. Training on the new coding system at all levels has also been required.
“Implementing any system requires training and software availability,” says Abdullah. “It took our organisation around three years to adopt ICD-10 and replace ICD-9. The coders had to take distance-learning courses with HIMAA [the Health Information Management Association of Australia] and the software had to be replaced, plus the database on the health information system had to be mapped with ICD-10.”
Switching to an EHR management system isn’t easy – it’s a huge, fundamental business change, not just an IT project, says Magon, and it needs input from the clinicians who will be using the system and the board who will need to approve it.
“It’s about changing working methods and culture, and getting clinicians on side, many of whom have used paper records for years and can be resistant to change. It’s not because they’re luddites; rather, many feel that medicine has been forced to work the way IT systems have been designed rather than the other way round.
“That’s why many attempts at introducing electronic patient record systems have failed. Hospitals have just digitised the whole record but paid little attention to how clinicians will actually then engage with it on a computer. Systems need to be designed to not only replicate the old paper file, but also provide access to information within two or three clicks,” Magon explains.
“The best solutions deliver this but then integrate with other clinical systems, so staff have a holistic view of a patient without logging in and out of lots of different applications. Once you then introduce workflow, e-forms and offer access via mobile devices, you create a modern repository of useful information accessible and usable by all. Legacy case notes also contain misfiled information that is not easy to identify; digitisation and recognition technologies, when applied correctly, can help solve this.”
Stay in touch
When it comes to digitising records, Abdullah believes you also have to pay attention to regional and cultural differences when developing a patient record management system: “You always have to bear in mind when implementing any system the culture of the regions and their healthcare system,” she says. “Is it socialising medicine? Are money and reimbursement the drivers? Or are safety, quality and research?”
“The drivers behind digitising patient records vary from hospital to hospital, and depend on their specific commercial and clinical needs,” adds Magon. “In the UK, the government has been pushing the National Health Service to become paperless at the point of care, and there are many initiatives under way to review each organisation’s digital maturity and then put in place transformation plans.”
“The key thing to understand is that there are many ways to get rid of paper and go digital. It is the application of technology, not the technology per se, that is key, and this is driven by commercial imperatives and goals that need to be discussed and agreed at board level.”
It’s also important to think about the future, says Magon. It’s necessary to plan from the outset how the system could evolve to incorporate direct entry of notes using tools like tablets or smartphones, as well as incorporating digital dictation, e-forms, workflow and so on. He says the system is an evolving database of information that needs to adapt to how clinicians want to use it.
Abdullah is in favour of the smartphones and tablets that are becoming commonplace in hospitals. “Most hospitals now use tablets in the patient units,” she explains.
“It makes it easy to document immediately rather than writing on a piece of paper, and then going to the nursing station and entering the information from there.”
Magon agrees: “It doesn’t matter whether hospitals are publicly or privately funded, they all have finite resources; exploiting lower-cost IT is therefore crucial. The ‘consumerisation’ of devices is certainly helping, with more hospitals using tablets and smartphones.
“For example, hospitals are looking at new ways for clinicians to record outcomes after consultations by introducing voice and handwriting-recognition solutions. Years ago, it would have cost thousands to do this, whereas [today], a $500–600 tablet can be used. The same is true with apps and cloud-based technologies.
“All this is driving significant and positive change within hospitals,” Magon concludes. “It is important to choose the right equipment because there isn’t a single solution that will meet all requirements.”
