Clinical notes technology helps bring order to ER, clinic

There is an old joke about doctors having the worst handwriting in the world. And there is an old adage that there is a kernel of truth in all humor.

THE PROBLEM

At Falls Community Hospital and Clinic in Marlin, Texas, it was much more than just a kernel of truth.

“We had totally illegible handwriting on the T-Sheets used in the emergency room, which made reading and deciphering a scanned document nearly impossible,” said the hospital’s CEO Jeffery Lyle. “This made it very difficult for the next provider seeing the patient, especially if the patient could not provide the information.”

Further, caregivers had to close the patient record to go back and forth between different sections of the medical record for needed information.

“If you have access to the technology to build your own templates, do so.”

Jeffery Lyle, Falls Community Hospital and Clinic

Additionally, clinic visits entailed lengthy documentation with multiple sections on each complaint and/or diagnosis. Patient face-to-face time with their provider was diminishing and provider documentation was growing.

“Patients felt the wait time to see their provider was longer than the actual time that was spent with the provider,” Lyle recalled.

PROPOSAL

To overcome this challenge, the 36-bed hospital and clinic turned to vendor Empower’s Physician Notes system, provider documentation technology that is a complementary offering to the provider organization’s Evident EHR.

“This is a new type of note template to make providers documentation much easier and faster,” Lyle explained. “The Physician Notes template would give the providers a choice of the information they specifically wanted in their documentation. The filters could be changed even as a note is being created.”

A note could be saved to a doctor’s favorites, where the doctor could open it with one click and begin documentation. For example, “Provider ER Note” or “Provider Trauma Note.” These would be pre-populated with generic information; doctors then add the patient information.

MARKETPLACE

There is a variety of physician documentation software on the market today. Many EHR and practice management have modules for this task. Some of the vendors of physician documentation technology include AdvancedMD, Cerner, ezDI, Meditech, M*Modal and Nuance Communications.

MEETING THE CHALLENGE

“First, a meeting was set up with one of the original physicians to observe real-time documentation on a patient’s chart,” Lyle explained. “We discussed the pros and cons and spoke with their staff in the ER and in the clinic as to their charting time and how it was affected with the use of the new note technology.”

Lyle and his team then chose a clinician to assist with the development of the note-taking templates. They would create a template, the clinician would tweak it, and the team and the clinician would review the template together.

“Once we decided it was workable, the clinician would try it out in the ER,” Lyle said. “As we progressed to several templates, we then began instruction with other providers in the ER. We then brought the clinic director, Kim Becker, into the notes process to help develop a clinic template that would meet their needs.”

With trial and error, a very workable and easy template was created and put in place. Clinic providers were educated on the template and offered their suggestions during the trial process.

“The ER staff and clinic staff are happy with Physician Notes and continue to have suggestions for improvement,” Lyle said.

RESULTS

Falls Community Hospital and Clinic had many tangible results after using the new note-taking templates:

• In the ER, the team reduced 75 manual charts to six notes templates.
• The readability of Notes has led to fewer insurance denials, resulting in a higher claim success rate and a healthier bottom line.
• New provider training time has gone from 12-24 hours to 2-4 hours.
• Charting time went from 25-30 minutes to 5-6 minutes.

“We have had an increase in productivity, the output per hour of work for providers in the ER and in the clinic; an increase in provider satisfaction; an increase in efficiency; patient satisfaction has improved as the Notes templates allow the providers more time with the patient and less time documenting; and providers no longer have to stay late, come in early or spend their lunch hour catching up on their documentation,” Lyle reported.

Providers have fewer corrections with their charts from the medical records department with the efficiency of the new technology, he added.

ADVICE FOR OTHERS

“If you have access to the technology to build your own templates, do so,” Lyle advised. “The change in your providers and patients will be very much worth the time and effort during the startup phase. Choose a vendor that is willing to work with you to create templates for your facility. Whether large or small, the templates are adaptable for your facility and you make the choice of the content.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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