By Jessica Kim Cohen
It’s no secret clinical documentation practices frustrate surgeons. However, emerging technologies such as machine learning, cloud computing and voice recognition can chip away at their concerns, improving physician satisfaction while strengthening ASCs’ reimbursement.
In healthcare, clinical documentation has become an important part of patient treatment and business processes. However, it’s a system many physicians find time-intensive. Today, physicians tend to spend half of their day on “desktop medicine,” such as completing patient notes, reviewing test results and communicating with patients online, according to a 2017 study.
At ASCs, a particular area of concern is procedure documentation, a set of notes that clinical and business staff often reference to glean information they need about individual cases.
To assess what ASC leaders are looking for in surgical documentation tools, Provation – a provider of clinical productivity software solutions – convened a roundtable discussion with 20-plus administrators, CEOs and physicians from surgery centers and specialty practices at the Becker’s ASC 25th Annual Meeting: The Business and Operations of ASCs conference in Chicago on Oct. 19.
“When you talk to physicians and leaders like yourselves, you really get to the core of whether providers are getting what they need from clinical and procedure notes,” Michael DeRosier, regional vice president of sales at Provation, said at the roundtable. “Many times people will say: ‘There’s an opportunity for improvement.'”
Here’s why procedure documentation poses a challenge for clinicians practicing at ASCs, and how emerging technologies can revamp the system:
Why procedure documentation is a challenge
Procedure documentation is not only a useful tool for clinicians looking to support a patient’s care, but also for medical coders, who use these notes to produce insurance claims.
“The bar’s been set very high for all of us, because it’s not just the note for the physician,” said Michael McMurtry, MD, medical director at Provation. “It has a lot of other uses.”
When coders scour these procedure notes for billing purposes, for example, specificity is paramount. Details documenting the length of a procedure or the severity of a patient’s condition – which translate into billing charges by coders – are extremely important to how payers calculate reimbursement.
However, this proves challenging for clinicians who are asked to build these procedure notes, since they often aren’t trained in medical coding. “Your physicians are obviously experts in their space and at their craft,” Mr. DeRosier said. “Because they’re experts at what they do in their space, [they] should have expert tools and deliverables to help them with everything they do on a daily basis.”
But to get clinicians on board with a new set of documentation tools, a facility can’t just deploy any system – it has to be an intuitive solution that doesn’t burden physicians, but rather helps them save time.
“It needs to be efficient and quick,” Mr. DeRosier added. “It can’t take a doctor 15 minutes to do a note. It kills turnover, it kills physician’s satisfaction – the list goes on and on.”
What surgeons want: Usability
There is one key feature clinicians are seeking in all their electronic systems – procedure documentation included – and that’s usability.
This proves especially challenging in the ASC space, as accurate documentation becomes more challenging with complex procedures, including specialty surgeries, according to Mr. DeRosier.
“A lot of physicians will say they’re inefficient when it comes to their procedure documentation, because it takes too much time,” he said. “These doctors tend to be dissatisfied with the templates or the tools they’re using.”
To address this challenge, Provation is working to integrate new technologies into its intelligent procedure documentation platform, Provation Apex, to make clinical workflows more intuitive for surgeons and physicians. These technologies include cloud computing, which allows users to access the tool from any internet-connected device, and voice-to-text, which can help physicians easily enter information into their notes.
The platform provides clinicians with templates that allow them to check off and customize entries on the type of procedure conducted, major findings and a patient’s postoperative instructions. The platform also offers documentation on what equipment was used, potential complications, estimated blood loss and medications, among other details and images.
One of the capabilities Mr. DeRosier said he was most excited about was machine learning, which allows Provation Apex to learn over time, rather than having to rely only on programming like in typical software. Provation Apex uses machine learning to track what procedures individual physicians are most often performing and uses these insights to inform their favorites over time.
“If a doctor does 50 ACL reconstructions, the software learns what type of cases they perform, what types of clicks they make, and drives the surgeon to the content and deliverables that are specific to them,” he explained. “It’s making an intuitive workflow and making it quick and easy for doctors to do their note and then move on with their day.”
Raymond Phillips, MD, a gastroenterologist at Naples, Fla.-based Gulfshore Endoscopy Center, said Provation’s documentation solutions have enhanced his facility’s mission to make each case more efficient. Although Provation only recently released its cloud-based Provation Apex platform, Gulfshore Endoscopy Center has been a customer of Provation’s on-premise tools since 1999.
“As a single-specialty ambulatory endoscopy unit there’s tremendous pressure on us to get patients in and out with a good experience,” he said. “Over the years, the requirements for documentation – for example, the time during the procedure – has been quite demanding. Provation has allowed us to meet these documentation requirements that are being put upon gastroenterologists.”
To learn more about Provation Apex, click here.
This article originally appeared on Becker’s ASC Review on Nov. 8, 2018. The original article can be found here.