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Amdis future e documentation_panel_hamen
1. The Future of Clinical
Documentation
and the Team Care Paradigm
Physician â Computer Connection
Panel Presentation
Ojai, CA
6/27/13
Claus Hamann MD, MS, FACP
2. ïȘ Getting coordination of care right is the key challenge to
achieving the Triple Aim.
ïȘ Our current notes paradigm isnât ready for care
coordination prime-time.
ïȘ We need to expand our physician notes paradigm to
include
ïȘ Clinician colleagues
ïȘ Patients
ïȘ Outcomes of our Plan/Care
Take-Home Messages
3. ïȘ Goals: Clinical relevance, quality, efficiency
ï§ Illegibility ï Unreadability
ï§ Is it only about the coding?
ï§ Do we decouple notes from billing?
ïȘ Data format:
ï§ Templates â narrative
ï§ Structured â free-text
ïȘ Data entry: Keyboarding â voice recognition
ï§ Documentation at the speed of thought?
ï§ Video recording?
ï Documentation for the Care Continuum
Key Challenges
for Clinical Documentation
4. ïȘ Choose most appropriate and usable documentation
method based on clinical workflow and note content
requirements
ïȘ Avoid requiring one particular method,
e.g. structured documentation forcing categorical
data entry
ïȘ Support coordination of care, patient navigation
Principles of Clinical eDocumentation
Adapted from Rosenbloom ST, 2010
5. ïȘ eRx
ïȘ Use of EHRs
ï§ Meaningful Use
o accurate procedure information
o transitions of care
ïȘ Physician employment
ïȘ Fee-for-Value
ï§ Document for Value?
ïȘ Hospitalism and Continuity of Care
ï§ Coordinating care through transitions
ï§ Transitions of care processes ï documentation challenges
Tipping Points
Effect on eDocumentation
7. Our patientsâ needs:
ïȘ Chronic illnesses, disability
ïȘ Engagement
ïȘ Multi-specialty team care
ï§ Interdisciplinary care planning, decisions
ï§ PCMH, group visits
ïȘ Value-based, integrated care
ïȘ Care outcome â Quality
Clinical Notes, eDocumentation
and the Team Care Paradigm
8. âŠand our electronic capabilities prompt us to extend our
documentation paradigm.
ï§ Preserve and include the patientâs voice, narrative
ï§ Expand âPlanâ to include provider colleagues, patients
ï§ Add Quality to SOAP ï SOAP-Q?
ï§ Extend the Problem-Knowledge coupler to the Problem-
Knowledge-Action tripler
ï§ Embrace post-acute, coordinated care and its
documentation, andâŠ
ïâŠtake aim at the documentation tipping point!
Our patientsâ needsâŠ
9. ïȘ Getting coordination of care right is the key challenge to
achieving the Triple Aim.
ïȘ Our current notes paradigm isnât ready for care
coordination prime-time.
ïȘ We need to expand our physician notes paradigm to
include
ïȘ Clinician colleagues
ïȘ Patients
ïȘ Outcomes of our Plan/Care
Take-Home Messages