Point of care documentation: A call to action

Driven by the Affordable Care Act, which was put into law in 2010, electronic health records (ehr’s) and their usage has soared. According to the Centers for Medicare and Medicaid Services statistics, approximately 95% of hospitals and over 60% of ambulatory practices attested for meaningful use in 2016 using a certified EHR. Out of the drive for EHR adoption, came the need and desire for Point of Care (PoC) documentation. PoC documentation provides the ability for clinicians to document patient findings and assessments, as well as plans of care while at the patient’s bedside or while in the exam room. Documenting real time while interacting with patients, creates many benefits as well as some challenges. Nearly all electronic medical record vendors supply some form of PoC Documentation which is defined as documenting the patient’s clinical findings while in the room with the patient or at their bedside.

PoC documentation provides numerous benefits to both clinicians and patients. Integrity and accuracy of data is increased by entering it “real-time”. No longer is there a need for hand written notes or simply to “remember” the details of the patient interaction. Timeliness of making the patient’s encounter findings available is also improved as documentation is immediately made available to other care givers, which is critical in settings where patients are attended to by multiple disciplinaries within the same encounter.

Efficiencies in assessing and billing are improved due to both accuracy and timeliness. By providing the appropriate tools at PoC, Providers (who are the most qualified to enter problems and diagnosis) can complete the documentation potentially eliminating downstream adjustments to visit diagnosis. PoC also increases the speed of getting such information to billing for processing and submission.

As healthcare moves closer to a shared risk, pay for quality model and farther away from a fee-for-service model, management of the patient’s problem list and degree of “sickness” will become more critical. Contracts will be executed based on the “sickness” level of a population and if not accurately described by the problem list, institutions will potentially lose millions of dollars by underestimating the cost for caring for their population. By providing PoC documentation, providers and other care givers can be provided with the tools to quickly and accurately manage patient risk scores and measures of estimated care which are needed from a financial perspective.

In many instances, PoC documentation systems are not user friendly. They require too many “clicks” to navigate, information is buried and difficult to obtain and tools are difficult to use to capture critical patient information. Obstacles such as these serve only to undermine the benefits as described above. Studies have shown that providers spend more than 50% of their clinic day using the EHR as opposed to interacting with the patient. Too much time is spent on finding information while trying to describe what is currently going on with the patient.

Also access to the EHR can cause problems. Firstly having to find a workstation and then traditional workstation setups require the provider to turn their back to the patient in an attempt to document the findings

In order to achieve the benefits of PoC documentation and minimize the obstacles for adoption, healthcare IT vendors must take responsibility in creating tools and applications that allow providers and other clinicians, the ability to document easily and efficiently at the PoC. It is critical that the right information at the right time or the right place is made available. No longer should users have to hunt for information but rather it should be immediately in front of them and even predictive in nature.

PoC solutions must also be flexible in their approach. The user should not have to adapt to the system but rather the system should adapt to the user. Making documentation flexible and adaptive to changes of circumstances is a critical feature. Templates should be flexible enough to allow the user to adapt to the data collected through the patient consultation without requiring the user to switch “templates”. It must also be intelligent in predicting the needs of the users. Certain diagnosis and problems generate the need to review specific data. The system should be intelligent enough to present that data to the user at the appropriate time and place without intervention from the user.

These systems must also provide a number of different entry mechanisms. These include point and click, typing, voice to text, copy and paste and conversion of handwritten to text. Providing the correct choice for users will minimize the need for dictation methods which although complete the documentation, provide no benefit for discrete data collection or analytics. Systems must also provide a variety of platforms from which the user can gain access. Waiting for a terminal at the nurses’ station or having to login to workstations in every exam room provides workflow complications that potentially slows the care delivery system. Users must have the flexibility to utilize mobile devices as well as workstations in order to complete their work.

As artificial intelligence develops and the requirements of taking care of our patients in a safe, efficient and cost-effective manner increase, it is critical that we continue to look for future development and improvement in the solutions that are being offered.