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Written by: Mediware on Wednesday, February 6, 2013 Posted in: Acute Care Rehab, Inpatient Rehab, Other, Outpatient Rehab

Having recently returned from a sales meeting where I had the opportunity to discuss meaningful use and accountable care initiatives, I was struck by a sense of disconnect between those who use healthcare information technology and those who sell it.

The focus of my discussion was upon the value of patient care as described by the change in the patient’s status divided by the cost to achieve it. What appears to be a simple concept presents many difficulties to those who earn a living by using or providing the tools necessary to demonstrate value. I think this difficulty stems from a difference in expectation of how technologies, specifically electronic clinical records, should be used to demonstrate the value of patient care.

As a clinician, I have spent many agonizing hours complying with the requirements for documentation in the medical record. Any and all assistance to ease this burden was welcomed and appreciated. Complete accurate and timely entry was the expectation. The payback was speed and convenience to accomplish these tasks. Systems that completed these tasks (such that anyone looking to the medical record to justify what was performed in treatment) could sufficiently satisfy any auditor’s inquiry.”

Listening to sales executives describe their experience with providers in rehabilitation gives me the impression that speed and convenience in minimal documentation compliance is all that clinicians expect; the message focuses on meeting these limited needs with electronic clinical record systems.

Clinicians, you are not taking the opportunity to demand that healthcare documentation technology provide you with more than an electronic filing cabinet for the medical record. Anytime you have the occasion to inform a sales executive about your needs, go for it and express what it is that will help you improve the value of patient care. As we move clinical delivery into the digital world of information and communication, recognize the potential to answer the questions you have sought to answer your entire career but had neither the time nor the information sources to answer. Beyond the electronic record system these executives are selling is the knowledge about patient care delivery effectiveness . That knowledge is linked to the history of how we practice and who has benefited. What is learned will direct future practice.

As the Patient Protection and Affordable Care Act and insurance payment requirements impose increasing demands on what and how data needs to accompany the bill, capturing these data as part of clinical documentation requirement becomes an added burden for all. Electronic record systems must provide this with speed and convenience. As important as reporting these data to others may be far more important is what these data may say when aggregated and analyzed with greater meaning and use for clinicians. The electronic record system must enhance each clinician’s knowledge of their clinical practice with a clear understanding of the value they contribute. The next time anyone asks what you need in a clinical record/information system tell them you need to know how to be more effective in treating patients. This will quickly change the conversation to meaningful use; and how the electronic clinical record should optimize the value of patient care.

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