Reduce the Burden: Refocus on Patient Care, Clinical Collaboration.
In a recent FPM article entitled “Notes 2.0: Reducing Documentation Burden,” the authors discuss the how to utilize EHR software features and Process Improvement techniques to lessen the documentation burden on Qualified Healthcare Professionals during Evaluation and Management encounters.
It’s a wonderful article, chock- full of familiar consultant-speak that makes perfect sense for those of us who live in the EHR world. But that’s precisely what concerns me. There is a well-documented, never-intended burden being placed on medical practitioners: they're expected to be software gurus and business process experts—and it shows up front and center in this article. Ultimately, the doctors who penned the article are right in their holistic view, but if I was to advise them, I would suggest a more direct path to a measurable, positive Return on Investment.
The primary output of Evaluation and Management services is the cognitive work produced a physician or other qualified healthcare professional in diagnosing and treating a patient’s illness or injury.?Documenting that cognitive work related to a specific patient encounter—clearly and concisely—is critical to quality patient care *and* optimal reimbursement.
The discipline is to define what information is essential, what is less so, and how to capture that in the patient’s encounter note for the date of service:
In consultant parlance, we have applied the Pareto principle to Clinical Documentation to reduce physician burnout. Doing so allows us to extract maximum value by focusing on the "vital few”. Said more plainly, capturing these essential elements in the patient’s medical record will enhance clinical collaboration, optimize reimbursements and reduce compliance risks.