The Case for EHR Optimization in Clinical Documentation

By January 6, 2016Blog

EHR optimization is not a standardized process. Effective optimization takes place when the application of process analysis, standards development and design criteria are applied in a holistic fashion.

The need to optimize clinical documentation systems has a genesis that varies. The transformation of electronic health record systems from a model that mimics paper-based documentation to a model for efficiency and appropriate standards suggests optimization can be a justified ongoing enterprise initiative.

When defining what entails EHR optimization, the general consensus is any process to move clinical documentation tasks from an existing defined state to one that takes less time to perform the same task is “optimized.” There is no hard-and-true measurement criteria or accreditation standard that must be met. Therefore, optimization depth and reach varies from one organization to another, and from one EHR vendor to another.

Preparing for EHR Optimization

Once an EHR system is initially built and rolled out to clinical teams for use, there are risks associated in changing documentation. Alignment of key components of an optimization initiative must be made in order to mitigate risks. To prepare, an optimization team should be deployed and guided through the discipline aspect of process efficiency.

Essential components of true EHR optimization include:

  • Analysis of clinical processes
  • Implementation of efficiency standards and the 80/20 rule
  • Effective training of clinical teams in the optimized environment

Clinical teams, providers and patients experience improved satisfaction when optimization is deployed. Patient throughput is increased, reduction of data entry error risk is realized, and increased time for patient care is realized. Long-term impacts are realized as well, as application of standards and design discipline is continued when building additional templates, or EHR upgrades are implemented.

Learn more about the benefits of EHR optimization for clinical documentation in the latest emids white paper.

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