Dr. Robert Budman, MD, MBA, and Certified Documentation Improvement Practitioner (CDIP) with AHIMA, is the Chief Medical Information Officer for Nuance Healthcare. He shares how physicians are navigating telehealth and in-person documentation during COVID-19 and the vital importance of clinical leadership in documentation improvement.
Recovery from COVID-19
Due to the pandemic, there was a drastic reduction in elective surgeries and in-hospital visits which impacted hospital revenue. Luckily, government grants, green lights on telehealth practices, and lifting of HIPAA and platform restrictions, have allowed hospitals to pivot and begin recovery.
Documentation for telehealth and in person care
Finding the balance between taking notes and documenting both in person and during telehealth visits is important. Dr. Budman shares that with the right technology, physicians can record these visits and turn these discussions into a viable progress note with very little editing, even during telehealth visits.
This is helpful for the physician and patient interaction. Benefits include:
—The physician is more present with the patient which improves care.
—Saves the physician time and frees them up from the documentation burden.
—Improves accurate coding which supports quality patient care and the organization’s revenue stream.
7:17 “I think what we’re seeing is a reinvention of the doctor patient relationship for the good through the use of technology and artificial intelligence because now the doctor is actually face to face and spending more time with the patient again. And the doctors are telling us that’s what they really want, and the patients are satisfied too. And then on the compliance end of things to produce a full and complete note is so important.”
This attention to detail and capturing the full patient picture is especially important during a pandemic for patient health, which reflects on your public facing quality scores.
Clinical leadership in documentation
For real change and improvement in documentation to occur, Dr. Budman emphasizes the importance of real clinical leadership. It can’t just be financial officers or people in the revenue department encouraging documentation. That doesn’t translate well to the practicing physicians.
Clinical leadership needs to focus on communicating that while these tools help with revenue, they can drastically improve patient outcomes and care quality which is what really matters. Detail and accuracy will allow your team to communicate and care more effectively.
12:55 “But the change management component of getting there is saying ‘This is what we’re going to do, we’re going to communicate it multiple times, we’re going to support it, it’s not going to come as a surprise, we’re going to track your results, we’re going to use those results to drive program performance, and regardless of making great software or not, the organizations that do well have the leadership in change management very strongly in their culture.”
Dr. Budman’s advice is to understand the playing field in healthcare and work with an expert partner to achieve real results for your patients and your organization.
Recover revenue and drive better financial outcomes