How Improving Physician Documentation Can Help Hospitals Manage Risks

Ask doctors why they choose to work in medicine, and more than likely you’ll hear it’s because they want to help people.

Yet despite their altruistic intentions, more than half of physicians (55 percent) find themselves embroiled in a medical malpractice lawsuit, according to a 2017 Medscape report. Though many of these suits are settled before going to trial, they can still end up damaging doctors’ reputation and costing hospitals millions of dollars. Most physicians cited a missed or delayed diagnosis as the top reason for litigation against them, followed by complications from treatment or surgery and poor outcomes.

Nearly a quarter of physicians (22 percent) said that if they could have done anything differently to prevent the situation, they would have had better chart documentation. Though electronic health records (EHRs) can offer a vast improvement over using handwritten notes, dictation or paper templates to document care, EHRs have gotten more complex over the years as regulatory demands like Meaningful Use have increased. Many of the enterprise EHRs used in hospitals today can be out of step with the increasingly hectic workflow of physicians, which may force many to jot down or dictate notes to decipher later or rely on shortcuts like copying and pasting and autotext, which are prone to errors.

Not only does clunky EHR software complicate clinical documentation, but it may also require physicians to spend as many hours on the computer every day as they do caring for patients. Mounting paperwork is a leading cause of physician burnout, which jeopardizes patient safety and fuels as many medical errors as unsafe hospital conditions, according to a study by Stanford University School of Medicine researchers.

With growing patient demands and regulatory pressures facing physicians every day, hospitals need solutions for making EHR documentation more intuitive and seamless in an effort to avoid medical errors and better manage risks. While this might sound like a doctor’s worst nightmare, there is an answer that can help providers steer clear of mistakes.

One way to ease the tension of risks is to choose an EHR that complements the workflow of physicians and includes integrated solutions that help simplify charting, documentation and order entry, allowing clinicians to spend more time with patients while creating a detailed record of their interactions with them.

Designed with the end user in mind, innovative documentation experience features:

• Chart: A streamlined display of information that allows clinicians to enter, review and update any essential clinical data in a snap.

• Note: Physicians can not only enter but also review all notes regarding a patient’s current and previous encounters. Even better, clinicians can also create new notes from customizable templates.

• Order management: Aside from simply entering in new orders for patients, order management also provides a workspace to discontinue, modify, suspend or reorder efficiently and intuitively.

It's also important to consider an EHR that optimizes documentation for improved patient safety and risk management. For example, MEDHOST partners with The Sullivan Group (TSG) to help support hospitals using our Emergency Department Information System (EDIS) with the following benefits:

• Help with identifying seconds-to-minutes emergencies: Using TSG’s Risk Mitigation Module (RMM), a library of risk and safety content programmed into the EHR, EDIS flags top patient complaints like chest pain that are frequently misdiagnosed and may indicate a range of high-risk conditions. These alerts appear in red on the patient locator board, helping clinicians triage high-risk patients within seconds to minutes and pinpoint what treatment they need.

• Fast consults to prevent bottlenecks: EDIS provides emergency room doctors and nurses with outside expertise they can quickly access when encountering mysterious symptoms or treating a complex case. Clinicians can link to these resources without clicking out of the patient chart, saving them time and helping them diagnose, treat and move patients through the ER faster.

• Insights for improved communication: Clinical risk content built into the EDIS not only help alert physicians to the potential for missing or delaying a diagnosis, but it also helps drive suggestions for tests and treatment that care teams may not have previously considered, along with producing documentation that can give clinicians an extra layer of protection in managing against risks.

MEDHOST streamlines documentation for physicians and helps them improve efficiencies, make better decisions, and enhance patient safety and care. If you’re ready to get started, email us at inquiries@medhost.com, call 1.800.383.6278, or  visit www.medhost.com.