Electronic Health Record (EHR) Documentation is an efficient way of recording and enables healthcare providers in sharing patient information electronically. It provides a comprehensive overview of a patient’s health, including data such as family history, lab results, medications, and clinical notes. Furthermore, it allows healthcare providers to monitor patient health changes over time and make evidence-based medical decisions.
However, physician documentation challenges are inevitable, especially if the EHR system is at fault. As a result, these issues may lead to EHR and physician burnout, which can be very frustrating.
Let’s take a look at the EHR documentation challenges and their impact on physician workload.
6 EHR Documentation Challenges and Their Impact on Physician Workload
Most physicians are only aware of the challenges of EHR implementation because it is a complex technological process. However, what about the documentation along with it?
1. Spending too Much Time on Clinical Documentation
In the US, doctors are overwhelmed with the amount of time they should spend on using EHRs. On average, they spend 16 minutes and 14 seconds using EHRs, primarily for chart review (33%), documentation (24%), and ordering (17%). Well, it’s understandable that physicians may need to spend more time on clinical documentation due to various factors, like lack of training, complex EHRs, higher documentation requirements, and disruptions. Nevertheless, if the electronic medical record documentation has a poor user interface and system design, it may not be efficient and prone to errors.
Unsurprisingly, spending too much time on clinical documentation is a significant problem for doctors in the healthcare system. Not only does it limit the number of patients you can see, but it can also cause other issues. For instance, if you’re stuck in paperwork, you won’t be able to give the patient the attention they need and may miss important details that could lead to errors in diagnosis and treatment. Additionally, this extra documentation time can lead to EHR and physician burnout and fatigue, making you less effective in your job. Healthcare systems must find ways to reduce the amount of time doctors spend on clinical documentation to make sure patient care is up to par.
2. Meaningful Use – Merit-Based Incentive Payment System (MIPS) And Medicare Access and Chip Reauthorization Act of 2015 (MACRA) Documentation Requirements That Dramatically Slow Physicians’ Productivity.
As a physician, you always know that MIPS and MACRA documentation requirements require so much time for paperwork and reporting. Moreover, these documents can be challenging to understand and comply with. There are two reasons why:
1. The language used in the MIPS and MACRA documentation requirements is highly technical and hard to comprehend. As a result, you may need help following the proper regulations.
2. MIPS and MACRA documentation requirements are constantly changing — making it challenging to keep up with the latest changes.
Beyond that, if EHR systems aren’t up to the task, doctors could spend more time on clinical documentation and reporting, leading to extra work and exhaustion. Likewise, the requirements may call for physicians to document the same information multiple times, which could create a duplicate effort and needlessly use up resources. This situation leads to EHR and physician burnout.
3. Documenting Clinical Visits for Longer Hours
Physician burnout may result from documenting clinical visit notes for longer hours, which involves your personal time. You may have to extend your working hours for the following reasons:
- Ensure that the documentation is accurate, complete, and up-to-date.
- Document patient visits for billing purposes, as well as for legal reasons.
- Provide additional quality patient care, such as discussing treatment options or providing education about illnesses or other health-related topics.
While all these reasons contribute to quality patient care, using your personal time for EHR documentation is not recommended. If you allow it, it can lead to physician burnout. It takes away valuable time you could spend on self-care, family time, or other activities that reduce stress and improve well-being. The situation may negatively impact your workload and decrease your satisfaction at work.
4. Inefficient EHR Software That Leads to a Lot of Additional Documentation Time.
An inefficient EHR software can cause you to spend more time on clinical documentation because it requires extra steps to find patient information, enter data, and navigate the system. Also, if the electronic medical record documentation system isn’t user-friendly, it can contribute to EHR burnout and frustration. EHR systems can also lead to inefficiencies and errors, especially if they’re outdated or have slow systems. Consequently, EHR software with inefficient performance can delay documentation because of lag times. In this case, you’ll probably need to outsource some of your clinical tasks.
5. The Decline in Patient Focus Due to Documentation Requirements
With the demands of electronic health record (EHR) documentation continuing to grow, staff may spend less time on direct patient care. This situation can be stressful and overwhelming. Moreover, they may be less inclined to engage in meaningful conversations with patients and their families, resulting in lower patient satisfaction. Suppose the EHR system is not designed correctly or implemented; it can add more to the EHR documentation burden and staff frustration, potentially leading to a decrease in the amount of time staff spend on patient care.
Meanwhile, the risk of copying patient notes forward – also known as ‘cut and paste‘ – can significantly affect the accuracy and integrity of electronic health records (EHR). This practice can lead to mistakes and inconsistencies in a patient’s medical history and keeping irrelevant information. It can also make it harder to spot changes in a patient’s condition, which can mean they don’t get the proper diagnosis or treatment and can put them in danger. And it can also increase the risk of fraud and malpractice, as it can be hard to tell who entered which information and when. To prevent this risk, healthcare organizations should have policies and procedures that help detect copied notes in EHR systems.
6. Lack of Training in Electronic Health Record Software
In the absence of proper EHR training, you may experience a few unfortunate outcomes:
- Staff not trained to correctly use and document patient information can make medical errors and mistakes.
- It can delay care when staff cannot use the system efficiently, negatively affecting patient satisfaction.
- It can reduce the efficiency of the healthcare system when staff takes longer to complete tasks because they need to familiarize themselves with the system design, resulting in longer wait times for patients and decreased healthcare efficiency.
Therefore, audits are necessary. Doctors and senior nurses review the medical record in clinical documentation audits to identify clinically implied diagnoses. Its goal is also to identify and correct any errors or inconsistencies in the patient’s EHR and to ensure that the information is helpful for patient care, billing, and quality improvement.
Overall, clinical documentation audits serve to determine compliance with HIPAA and CMS regulations, which can prevent penalties and legal repercussions.
How to Improve EHR Documentation In Healthcare
Since healthcare technology, codes, and communication between providers and coders continue to change, it is essential to improve healthcare documentation continuously. Staying current requires constant communication among all healthcare personnel. Likewise, here are five ways to improve EHR documentation in healthcare:
- Provide training and support to staff on how to effectively use the EHR system. This process can include training on how to navigate the system, as well as on best practices for documenting patient information. Additionally, practices can provide regular updates and refresher training to ensure staff uses the system correctly and efficiently.
- Implement a streamlined documentation process. You can capture all relevant information by using templates and providing checklists and reminders.
- Establish a quality control system to ensure the Documentation is accurate and complete. You should include regular audits of patient records to identify errors or omissions and give feedback to staff to help them improve their documentation skills.
- Utilize voice recognition software for your EHR system. It can help streamline the process of documenting patient information and facilitates fast and accurate transcription of patient information into electronic medical records.
- Offer your staff regular breaks and time off since it’s a great way to prevent burnout and keep them energized and fresh.
In conclusion, accurate and timely reimbursement is the main priority for any healthcare institution or clinic, which is why healthcare documentation improvement is so significant. Clinical Documentation Integrity (CDI) professionals should dedicate to documenting patient records accurately and completely. Therefore, healthcare providers like you can receive on-time payments.
Choose the Top EMR/EHR Software
To ensure quality EHR documentation, selecting an EHR that offers customizable applications with template capabilities is essential. The right software can help reduce the frequency of errors and EHR burnout associated with poor documentation practices.
Over the years, we have assisted medical practices with EHR/EMR selection, implementation, and software usage. We specialize in providing customized EMR/EHR software to meet your practice’s specific needs.
Schedule a demo or contact us through the contact form for more personalized information. Let’s work together to find the best software for your practice!
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