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Documentation Drivers for Effective Clinical and Patient Outcomes: Present and Future

Hess, Cathy Thomas BSN, RN, CWCN

Advances in Skin & Wound Care: February 2017 - Volume 30 - Issue 2 - p 96
doi: 10.1097/01.ASW.0000511881.03341.55
DEPARTMENTS: PRACTICE POINTS

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: chess@nethealth.com.

As we celebrate the 30th anniversary of this journal, we recognize that wound care documentation has come a long way with the implementation of specialty electronic medical records (EMRs). Today, we can enter data about the patient and corresponding wound information and provide that information in a secure fashion to collaborating healthcare professionals.

The specialty EMR’s interoperability allows collaborating physicians greater access to the patient record. Being able to download and store patient tests makes it easier to diagnose and treat the patient in a coordinated manner. E-prescribing is also widely used within the specialty EMR, allowing medications to be sent directly to pharmacies. Another important functionality of specialty EMR is clinical decision support alerts. When clinical decision support is applied effectively, it increases quality of care, enhances health outcomes, helps to avoid errors and adverse events, improves efficiency, reduces costs, and boosts provider and patient satisfaction. We can also apply a standard methodology of wound measurement and tissue analytics to assist clinicians in understanding the wound healing process.

The specialty wound care EMR can capture the work and assessment data using discrete data fields, which is critical to support the regulatory and quality mandates to improve quality, safety, and efficiencies. It is also imperative for accurate reporting. Integrating evidence-based guidelines and templates, standardized dropdown lists, and lookup tables can ensure quality data captured to support a meaningful platform. Developing core reports to manage your wound care practice, generating quality reports, and utilizing the data to improve patient and facility outcomes can assist to improve quality, safety, and efficiencies.

To efficiently manage your wound care practice, implement 3 smart methodologies:

  • Optimal workflows

Review current processes, documentation components, and data flows, identifying gaps in best practices and guiding recommendations for improvement in the clinical and operational workflow. This critical process will maximize your clinical and operational efficiencies, enhance clinical quality and patient safety, and streamline your current workflow to improve care coordination. Ensure the wound care practice’s workflow is up to date and customization of the specialty wound care EMR is accurate.

  • Capture accurate documentation

Document clinical and financial outcome data in a specialty wound care EHR. The data can be used to advance critical pathways, improve product formularies, validate contract fees with payers, and improve patient and physician satisfaction and comply with federal mandates.

  • Robust data reporting

The data collected allow you to observe trends across wound and patient types and clinical practices and operations. The data also allow you to compare clinical, operational, and financial outcomes through the data stored in the EMR system. To effectively interpret the report, it is important that you understand the report requirements, as well as the data inclusion and exclusion requirements.

The healthcare industry is constantly evolving and becoming more accustomed to the EMR guiding process. Examine your process because this is the key to successful documentation and reimbursement. Look closely at changes required to adapt to new technology, regulations, processes, and procedures. Clinical and operational intelligence lies within your smart EMR workflow.

As you move forward with your EMR, and review your checklist by considering the following:

  • scheduling module to coordinate patient visits and productivity
  • patient and physician portals to engage in the quality metrics
  • secure e-mail exchanges for coordination of care
  • smart EMR to meet the needs of all practicing clinicians and physicians in your department, as well as the patient who may access their defined information
  • clinical decision and practice management tools to alert the user to medication errors and adverse drug interactions and track test results and patient follow-up
  • interfaces to pull data in and out of your system and clinical and operational compliance and audit mechanisms
  • compliance with accreditation and certification standards
  • audit trail to identify work performed through documentation
  • reporting for outcomes and benchmarking

Keep documenting!

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