Unlock The Power Of Narrative Documentation

The healthcare industry is currently undergoing tremendous change caused by a myriad of issues which have been building over decades. These include:

• Rising healthcare costs that are not correlated with healthcare outcomes,
• Increasing ranks of the uninsured,
• Unsustainable Medicare and Medicaid programs, and
• Government efforts to transform healthcare.

Fundamentally, everyone – from providers to patients to payors – seeks a system that delivers quality care and avoids medical errors. It has been the focus of many Institute of Medicine treatises1, and careful implementation and deployment of Electronic Health Records (EHRs) is one way to achieve this. The impact on hospital CIOs and CMOs is clear. Healthcare organizations are driving their staff to rapidly adopt certified HER systems and demonstrate that providers are using them in a meaningful way. Unfortunately, today's EHR systems cause a number of challenges when it comes to clinical documentation.

As the industry races to adopt EHR technology driven by mandates and reimbursements, the crux of the problem is that clinical documentation fundamentals are being forgotten. Narrative dictation has played a dominant role in clinical documentation for decades for two important reasons:

1) Narrative dictation is the efficient method providers prefer.
2) Narrative dictation is the most effective way to capture the complete patient story.

Narrative documentation captures the full health story of the patient and as such, is critical for providing safe care, for communicating to the care team, and for downstream needs such as coding, billing and revenue cycle management. Physicians are at the center of the clinical documentation universe. A productive physician implies better patient care, better and more complete documentation, and better reimbursement.