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Amdis future e documentation_panel_hamen

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Amdis future e documentation_panel_hamen

  1. 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. 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. 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. 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. 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
  6. 6. Care Coordination Model Institute for Healthcare Improvement Adapted from Craig , 2011
  7. 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. 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. 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

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