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Concurrent documentation project wins trifecta

September 1, 2010
by Dennis Grantham, Senior Editor
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How one documentation project made clinicians, clients, and even accountants happy

Documentation speed jumps 360 percent

Compared to paper-based systems that depend on human memory, process, and judgment for completion of required elements of care that underlie specific diagnostic or billing codes, EHRs work behind the scenes, managing and presenting each client's information based on the role performed by defined system users. Starting with client intake information and an initial diagnosis, for example, MHCCI's EHR system helps pull the golden thread: ensuring a match between billing codes and work.

“The EHR links the billing to the discussion associated with it,” says Wilkerson. The result is far fewer human errors, far fewer rejected claims, and far more efficient treatments.

Because of the intensive involvement of front-line nursing and clinical staff with clients and client documentation, they were a logical choice to receive the first structured forms developed by Wilkerson's team and the first group whose work with the new process would be measured. Three quarterly measurements show, to date, that documentation time among these professionals fell, on average, from 11 minutes per session to just three minutes-a 360 percent improvement. According to Wilkerson, much of the improvement happened quickly, within the first quarter after the process change. He notes that documentation time, while down, does fluctuate based on the mix of forms that clinicians must complete during the quarter.

Figures 1A and 1B. Using the capabilities of their EHR system, MHCCI's process improvement team converted a general-purpose, paper-based progress note into a “structured” electronic form, in this case, tailored to the needs of a registered nurse. There's no need for all of the “fill in the blank” items at the top and bottom of the paper form since the structured electronic form relies on the EHR to store related information about the client, diagnosis, appointment, and clinician involved. Click here to view a larger version of Figure 1A. Click here to view a larger version of Figure 1B.

Figures 2A and 2B1 A medication training note on paper (2A) and in structured electronic form (2B). The EHR presents this note to the clinician during appointments when medications are prescribed as part of a client treatment plan. The note guides the clinician through the discussion, presenting discussion points associated with a related Medicaid billing code. By tying the details of electronic forms to the client's treatment requirements, the EHR helps MHCCI tie “the golden thread” that links diagnosis and treatment activity to the documentation required for reimbursement. Click here to view a larger version of Figure 2A. Click here to view a larger version of Figure 2B.

A surprise for clinicians

Wilkerson explains that, during its introduction, the concurrent documentation approach required clinical staff to interact with their clients in a new way. Clinicians would make notes during the course of an appointment, while a computer display screen enabled clients to observe (figure 3). When this change was piloted, it proved unsettling for some. “My biggest surprise with all of this was the initial resistance by some staff members to have clients read what was said about them. That piece threw me for a loop initially,” Wilkerson recalls.

But he could see where the clinicians were coming from. “It was a new process, and if a client disagreed with what the clinician typed in, a discussion had to occur. The differing points of view had to be brought together.”

Ultimately, it took time to develop consensus about how best to introduce the process to clinicians and clients alike. Wilkerson sums up the discussion like this: “The key to concurrent documentation is being able to document the information with the client. Most clinicians complete notes at the end of a session, summarizing what was discussed and learned, what the patient will be working on. So, we say to the clinician, ‘You're going to do [the notes] as you learned, but now, you're going to enter them in the computer at the same time that you give them to the patient.’ So, when the clinician is ready, he or she might say to the patient, ‘Let's go over here and draft our progress note, our summary, together.’”

Common ground with clients

“There are,” he continues, “a lot of positives that come out of that.” In addition to the comfort of clinicians being able to finish work sooner, Wilkerson says, “I often hear from staff members that they had one clinical impression, but that the client was thinking differently. Sharing [during the summary note process] helped to drive a different understanding, a common ground of understanding for the therapist and the patient.”

Clients have also had their say, says Wilkerson. “We've heard a lot of feedback that clients feel more involved-the process definitely supports a recovery-focused approach,” he notes. Quarterly surveys of client satisfaction/clinician engagement show a strong positive response.

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