Creating and implementing relevant clinical documentation standards is one of the most critical steps in adopting or optimizing a hospital’s electronic health records system (EHR). An essential part of any new clinical implementation—not overshadowed by the solution itself—documentation and content play integral roles in a hospital’s clinical and operational efficiency.
This article discusses a few things a hospital should consider when setting up clinical content and what they should expect from a knowledgeable healthcare IT implementation team.
Clinical content is a foundational element of an EHR. Notes, treatment plans, patient diagnosis care standards, test results, medication administration—all these and more are guided by uniform documentation. Thus, this entire content library must be given the utmost attention.
From a clinical perspective, nurses and physicians can perform with more efficiency and accuracy when they have a reliable solution for the entry, storage, and retrieval of evidence-based clinical content.
Operationally, setting clear and relevant clinical documentation standards is critical because of its close ties to improving the value of care. A better value often means reduced costs and maximized reimbursements.
Setting up clinical content requires collaboration from the facility and the EHR vendor. By ensuring this process includes critical decision-makers from both parties, vendor and facility can make sure documentation meets each specific need—clinically, operationally, and from a regulatory perspective.
An EHR vendor will support this process with implementation experts who have hands-on clinical experience in a best-case scenario. Putting this expertise at a hospital’s disposal enables a streamlined and informed approach to setting up clinical content.
For example, vendor and hospital users can create standardized naming conventions that don’t stray too far from previous models and make sense for specified workflows. Something as simple as uniform filenames can ease use and support a clinical team.
Also, an EHR vendor must have the expertise on hand to catch potential documentation issues that may not meet local, state, and government guidelines. It can be time-consuming for hospital staff to keep up with regulatory changes. Knowing industry standards and documentation policies is often a significant part of an implementation expert’s job. This degree of foresight will help prepare a facility to meet government guidelines such as Promoting Interoperability.
Even with the help of a skilled vendor, setting up clinical content is an intricate process. Facilities can reduce the stress clinical documentation can create by focusing on three key aspects—timeline, operations, and content governance.
Successful hospitals will work with their EHR vendor to lay out a realistic approach for setting up clinical content before a go-live event. We find the best practice is to identify and agree on any “must-have” documents or templates and use them for the first 120 days after going live.
The development of clinical content as it relates to operations entails various aspects. Every piece of documentation to be considered must address these points to avoid any operational issues in the future. They include:
Once an EHR is “live,” it is not unlikely for clinical teams to request changes to the content. At MEDHOST, we insist hospitals create clinical governance committees tasked with evaluating and prioritizing requests as they relate to your overall vision. A governance committee can also make sure any newly created documentation and roles standards follow the specified guidelines laid out before implementation.
In addition, a clinical governance committee defines the ongoing processes for clinically related content regarding—patient safety, continued education, onboarding of new staff, reviews, and maintenance. A facility can also encourage CMS guidelines like Promoting Interoperability and Appropriate Use Criteria through the governance committee.
MEDHOST takes specific care to introduce governance concepts and promote engagement within the organization.
All of the best practices and components outlined come into play during every implementation of any MEDHOST solution, whether migrating to a cloud-based EHR or adding a new revenue cycle solution. Our team of implementation experts claims decades of combined clinical experience to help hospitals find a clear pathway to standardized documentation that supports continued clinical and operational success.
To learn about how the MEDHOST implementations team can set you up for success now and into the future, reach out to us at firstname.lastname@example.org or call 1.800.383.6278.