Digital Minute: Documentation Optimization Project
By Walter Reiling, MD, system chief medical information officer, Premier Health; and Mandy Via, system director of access, referral management, and telehealth, Premier Health
As providers, one of our core tasks is documentation of our patient’s status and treatment. This task has evolved considerably over the years. Originally, it was purely to provide continuity of care over the patient's life. Notes have now become a part of the billing invoice, legal documents, and patient communication.
To support our providers in carrying out this important task in the most efficient way possible, Premier Health has recently launched a clinical documentation optimization team. This team will be working on many initiatives around documentation for providers, nurses, and other clinicians. Leading health care systems nationwide use this strategy to improve the quality and efficiency of documenting patient records.
In coming weeks, this team will start working to establish documentation templates and tools for our various specialties that help to integrate the needs of each of the focus areas for notes. The product of the work will consider the need for coding/billing elements, regulatory requirements, and risk management recommendations. Provider involvement will be essential to maintain the highest quality clinical content to support patient care. Another element will be to reduce unnecessary content, or “note bloat.”
Physicians and APPs will be engaged in these efforts, along with our physician advisor team, our billing and coding experts, and those who are most familiar with the regulatory requirements. Our digital health and technology team will provide technical knowledge and support. This project will extend into next year and beyond and has the potential to make our notes easier to create and more useful clinically while reducing the need for queries due to missing components.
Look for more information on this important initiative as it moves forward. If you have any questions or comments on the project, please contact me at wareiling@PremierHealth.com.
Back to the November 2023 issue of Premier Pulse
