Original article posted on HealthcareITNews.com.
Historically, physician and nursing systems and workflow have been parallel, but independent, of each other. EHRs are set up for the clinician and clinical documentation, and most do not provide nursing protocols or documentation, nor do they offer a patient engagement functionality. To accommodate all users, and even settings, large enterprises often run a number of EHRs and/or documentation tools to capture all data and documentation. The result might be that information is captured, however it is certainly not being shared efficiently, if at all, across the enterprise.
Fortunately, over the last year, nursing documentation tools that take care of all coding at the point of care have been developed and are interoperable with clinical documentation making it feasible to run one documentation tool across the enterprise. It is also possible to incorporate patient engagement and other allied health professionals into that one system and to even connect the enterprise and ambulatory settings under one documentation tool. The efficiencies that stand to be gained from unifying ambulatory and enterprise setting are significant and the benefits of providing clinicians with a clear picture of the patient are immeasurable.
At some point in the not-too-distant future, all persons who are involved in the care of a patient will be required to coordinate with each other. While that day has not officially arrived, the technology to facilitate coordination of care has. And, as many EHR users continue to become increasingly frustrated with interoperability issues and the inefficiencies that result from running a number of EHRs, documentation systems, and protocols side-by-side, this technology is sure to be a welcomed relief to many frustrated users and IT professionals.
Five key benefits to using one documentation tool across the enterprise:
1. Improved communications and workflow. With all eyes, and hands, working off of one system, care teams can literally work hand in hand to provide coordinated care for the patient. With protocols for nursing and all ancillary providers integrated into the system, clinicians can view care plans and nurses can see what therapies were administered in prior shifts without having to track down the care team for updates. Notes can be exchanged and communicated bedside minus the paperwork. Working off of one documentation system at the point of care will make it easier for doctors, nurses and therapists to share information and ensure that the appropriate care is being provided to the patient.
2. Real-time view. Clinicians need comprehensive, up-to-date patient information at the point of care. Period. Anything less is not comprehensive. With all users integrated into one system, the clinician in the ER can now view lab reports, patient records from ambulatory settings in real-time. Consequently, that same patient’s records from the event will be available as the attending physician is documenting. This benefit is a huge plus for the patient and stands to dramatically improve delivery of care.
3. Accuracy and Efficiency. Needless to say, automated coding and documentation increases accuracy. Today, the technology exists to have all documentation and coding requirements satisfied at the point of care. So, as a by-product of caring for the patient, the clinician and all users enter in the diagnosis and care protocols and the documentation tool takes care of the coding, satisfying all requirements. That means no ICD-10 coding or meaningful use documentation, leaving less room for error and no need for extra coding steps. This fluidity with all users on one system cuts down on the additional room for error. Imagine also having all users on one documentation system and how much easier it would be for your IT staff in terms of support.
4. Meaningful Use. With all users connected to the patient and the capability to integrate patient engagement, meaningful use including all of its current and future stages will be much easier to document.
5. Time and Money Saved. Can you imagine the cost savings alone of the busy healthcare professional who stops what they are doing during the course of a day or week and gets in their car, goes to their patient’s doctor’s office to get a file or x-ray out of utter frustration? Or the precious budget dollars that are wasted on running a number of disparate systems and their increasingly costly “workarounds” to facilitate less than efficient connectivity? One documentation system across the enterprise that unifies all users and settings will cut down on all workarounds, both technologically and physically. Wait, let me add “mentally” to that as well. Let’s face it, many of the workarounds and documentation challenges can be a real headache. I would not even want to begin to estimate the cost of those headaches.