Better Living—and Documentation—Through Computer Assistance

April 13th, 2015 / By Jeremy Zasowski

Have you ever driven a car without power-steering? It’s quite a workout. We used to all drive without power-steering and for “entertainment” you had to spend ten minutes twisting a small dial back-and-forth trying to get a radio station to come in clearly, only to drive under a bridge and completely lose it. Now we’re on the verge of self-driving cars and I can stream an entire album saved in the cloud into my car just about anywhere and anytime I want. No more fine-tuning that pesky radio dial.

We used to buy rolls of film and clunky cameras to take pictures, and then drove to a photo-developing store to drop off the film. We would wait a couple days to get the pictures developed, only to realize that the perfect shot we took from that weekend at the beach is blurry because of the sun’s glare on the lens, and there’s no way to go back and shoot it again. Now everyone has a digital camera in their pocket or purse through their phones, and we can re-shoot any shot a dozen times by just touching a screen.

Getting paid used to mean waiting for your company to print you a paper check and then standing in line at the bank to make a deposit into your account. Now most folks get direct deposit into their bank accounts and rarely set foot in a bank. You can do just about anything you need to do online through your bank’s online banking services.

From driving to taking photos to banking, life has gotten a lot easier through computer assistance. In health care, we’re constantly inventing new treatments and technology that improve patient care, such as robotic surgery, better imaging equipment and therapy customized to your specific genes. However, the process of documenting patient conditions and care provided, which is a key component of coordinating care, communicating between providers and ensuring appropriate payment for services, is still heavily reliant on manual work from providers.

Healthcare organizations have made substantial investments in electronic health records, and physicians have found that the ability to copy-forward content from prior documents can help to document a bit faster. However, this has results in new issues and risks associated with patient information and data copied in error into a new note. With ICD-10 soon to be implemented, physicians will be under even more pressure to add diagnosis details that they have never had to document before. I’ve heard the quote more than once, “I didn’t go to medical school to learn how to write notes, I went to learn how to care for patients.”

It’s time to bring more “computer assistance” to make documenting more intuitive and efficient for providers. Instead of having providers memorize the complex rules for diagnosis documentation needed for ICD-10, help them with intuitive prompts when more diagnosis detail is needed and then automatically update the medical record with their responses. And don’t turn off the copy-paste function in the EHR. Analyze all new notes created using computer-assistance to compare them against all prior notes for high-risk copied text and only notify providers when there is a high-risk issue.

Computer-assisted physician documentation (CAPD) is going to make a physician’s life easier, and result in more complete and compliant documentation. Start working smarter, not harder. Check out what 3M is doing with CAPD today.

Jeremy Zasowswki is marketing manager for 3M Health Information System’s Emerging Business Team.

How is 3M working to improve the accuracy of patient data and documentation? Click to find out.