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EHR Transition Is an Opportunity to Improve Documentation 

Work with providers, listen to their concerns, and help them achieve meaningful use of an EHR.

By Jennifer Hayes, DNP, FNP-BC, CPC, CPCO, CDEO, CRC, AAPC Fellow
Transitioning to an electronic health record (EHR) — whether for the first time, or from one system to another — can be daunting. Providers often express concerns about workflow disruption, and reduced productivity and revenue. Understanding the provider perspective can facilitate an approach to implementation that gains their buy-in, as well as allows them to be part of the process.
Here are strategies you can use to ensure your new EHR demonstrates quality of care and improves provider documentation practices.

1. Have Realistic Expectations

Providers are not professional coders and may have a hard time viewing the role of documentation through the coding lens. Good clinical documentation usually isn’t part of the curriculum for healthcare providers, and they may not recognize their own documentation deficiencies. Others may be averse to new technology. Engage providers and allow them to express their concerns and questions.

2. Identify Existing Issues

An EHR will not correct documentation problems that already exist. Calling attention to underlying inadequacies of the existing EHR system or paper charting will help providers to better capture patient clinical data. For example, medical necessity and appropriate chronic disease capture are two areas that providers did not emphasize in previous fee-for-service reimbursement models.
Appropriate documentation assessment remains a vital skill that certified coders hone daily. Encourage providers to partner with a coding specialist for review and analysis of their documentation practices.

3. Offer Support

Different office personnel will interface differently with the EHR, each requiring unique patient documentation capture. Support the various roles within the office to ensure a smooth transition. The coding specialist understands many roles in the provider office and can suggest ways to enhance complete and accurate capture of the encounter note. Health plans and hospital systems have invested in the transition to EHR systems and offer enterprise-wide training opportunities, as well.
It’s critical for those training to incorporate the EHR system-specific resources to understand fully the functionality and limitations of the chosen system. Demonstrate to providers how to take current documentation and integrate it into the EHR system will decrease reluctance to adopt.

4. Maximize Efficiencies

Providers want to care for their patients and not be bogged down with documenting. The clinical record supports many functions, from serving as a legal record to validating appropriate reimbursement. The role of the encounter note is to help build the EHR framework to maximize complete care capture, improve overall patient quality, and provide efficient care delivery. For example, many commercial EHR systems consider the Centers for Medicare & Medicaid Services’ (CMS) initiatives and provide prompts for things such as advanced directives. Systems may be customized based on practice type to embed clinical practice protocols into a template that supports providers in their clinical decision-making.
Templates within EHR systems are marketed as a tool to improve efficiency. Although there are benefits to using templates, you must also consider the risks such as “cloning” (inappropriate duplication of previous documentation). Educate providers to limit the use of copy and paste in their documentation capture. Instead, assist them in developing quick text options that require minimal manual entry, but allow for customization from patient to patient and visit to visit.

5. Complete the Feedback Loop

A notable benefit of EHRs is enhanced data capture, analysis, and reporting. Providers want to see the fruits of their labor, and should be given ongoing feedback and support. Consider implementing a provider scorecard to measure quality, coding, and financial performance. Recognize their success and remediate deficiencies. Most importantly, remember that the transition does not end when the EHR goes live. Deliver ongoing support and address concerns and challenges brought forward by providers after they have worked in the new EHR system.
A professional coder possesses the necessary expertise to understand clinical documentation and can play a pivotal role in an EHR transition. The depth of their knowledge allows them to formulate strategies to maximize documentation improvement opportunities. Executing an EHR conversion successfully will deliver provider confidence in achieving better quality of patient care, efficiency, and appropriate reimbursement.
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Meigs, S. L., & Solomon, M. (2016). Electronic Health Record Use a Bitter Pill for Many Physicians. Perspectives in Health Information Management, 13(Winter), 1d.
Saranto, K. (2014, July). Clinical documentation improvement for outpatients by implementing electronic medical records. In Nursing Informatics 2014: East Meets West ESMART+-Proceedings of the 12th International Congress on Nursing Informatics, Taipei, Taiwan, June 21-25, 2014 (Vol. 201, p. 102). IOS Press.
Towers, A. L. (2013). Clinical documentation Improvement—a physician perspective: Insider tips for getting physician participation in CDI programs. Journal of AHIMA, 84(7), 34-41.

Jennifer Hayes, DNP, FNP-BC, CPC, CPCO, CDEO, CRC, AAPC Fellow, has more than 25 years of healthcare experience in roles spanning from provider to coding manager. She is the manager for HEDIS, Quality and Coding at Highmark, and a member of the Greater Pittsburgh, Pa., local chapter.

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