1. The Future of Clinical
Documentation
and the Team Care Paradigm
Physician – Computer Connection
Panel Presentation
Ojai, CA
6/27/13
Claus Hamann MD, MS, FACP
2. Getting coordination of care right is the key challenge to
achieving the Triple Aim.
Our current notes paradigm isn’t ready for care
coordination prime-time.
We need to expand our physician notes paradigm to
include
Clinician colleagues
Patients
Outcomes of our Plan/Care
Take-Home Messages
3. Goals: Clinical relevance, quality, efficiency
Illegibility Unreadability
Is it only about the coding?
Do we decouple notes from billing?
Data format:
Templates ↔ narrative
Structured ↔ free-text
Data entry: Keyboarding ↔ voice recognition
Documentation at the speed of thought?
Video recording?
Documentation for the Care Continuum
Key Challenges
for Clinical Documentation
4. Choose most appropriate and usable documentation
method based on clinical workflow and note content
requirements
Avoid requiring one particular method,
e.g. structured documentation forcing categorical
data entry
Support coordination of care, patient navigation
Principles of Clinical eDocumentation
Adapted from Rosenbloom ST, 2010
5. eRx
Use of EHRs
Meaningful Use
o accurate procedure information
o transitions of care
Physician employment
Fee-for-Value
Document for Value?
Hospitalism and Continuity of Care
Coordinating care through transitions
Transitions of care processes documentation challenges
Tipping Points
Effect on eDocumentation
7. Our patients’ needs:
Chronic illnesses, disability
Engagement
Multi-specialty team care
Interdisciplinary care planning, decisions
PCMH, group visits
Value-based, integrated care
Care outcome – Quality
Clinical Notes, eDocumentation
and the Team Care Paradigm
8. …and our electronic capabilities prompt us to extend our
documentation paradigm.
Preserve and include the patient’s voice, narrative
Expand “Plan” to include provider colleagues, patients
Add Quality to SOAP SOAP-Q?
Extend the Problem-Knowledge coupler to the Problem-
Knowledge-Action tripler
Embrace post-acute, coordinated care and its
documentation, and…
…take aim at the documentation tipping point!
Our patients’ needs…
9. Getting coordination of care right is the key challenge to
achieving the Triple Aim.
Our current notes paradigm isn’t ready for care
coordination prime-time.
We need to expand our physician notes paradigm to
include
Clinician colleagues
Patients
Outcomes of our Plan/Care
Take-Home Messages