Why Electronic Point-of-Care Documentation is Better for Patients AND Caregivers
While electronic clinical charting is the new norm in most medical settings, true mobility in healthcare at home lags. It shouldn’t.
While electronic clinical charting at the point of care is a goal for most healthcare organizations, it’s often easier in the acute care or long-term care settings, as technology is often permanently a part of the care environment. In home care or “care where you are” settings, it becomes more complex as documentation requirements, home environments, the type of care and even the type of provider all varies. Home healthcare is the largest segment of “healthcare at home,” but there is also hospice care, private duty nursing care, personal private duty home care, continuous home care for the medically fragile, emerging types of care — such as pre-acute care (which aligns itself with “population health”) — and even mobile physician care.
Each of these types of home care can and should benefit from point-of-care documentation. While each of these types of care has challenges when it comes to documentation, for each there is a roadmap for successfully achieving electronic charting at the point of care.
The benefits of point-of-care documentation
When done properly, offering your field staff point-of-care clinical charting options can make a job easier, and can promote better patient care. If you talk to enough provider agencies, you’ll hear cautionary tales (see “Pitfalls” below), but don’t let them discourage you. If you’ve done your homework and are properly prepared, you’ll find that point-of-care documentation encourages:
It’s been estimated that for every one hour of patient care, two hours is spent on documentation that includes EHR/EMR navigation and “toil.” If you provide the right information at the point of care this time is reduced. Choosing a solution that is stable, available and user friendly enables the clinician to make the most efficient use of their time. The real benefit for the employee, however, is that the experience is more personal. When more documentation is done in the field, in the patient home or at the bedside, it’s not done by your employees in their personal time, which ultimately can increase their job satisfaction.
Much like the game of telephone where the accuracy of a statement deteriorates with each person that receives it and passes it on, clinical charting that isn’t done immediately risks the loss of accuracy. There are many agencies that have clinicians submit their work on paper then have data entry clerks input the information into the electronic health record. However, one overlooked risk of inaccuracy is the nurse or therapist who captures the basic information during a patient visit then completes the rest of the paperwork later. In some case, this might occur after the patient has seen four or five other patients when details aren’t as clear as they would have been had the information documented at the point of care. This could impact the accuracy of the Outcome and Assessment Information Set (OASIS), vitally important to home health agencies because it directly impacts reimbursement. In all cases, inaccurate information impacts proper care planning, and can cause inferior patient care.
If information needs to be relayed to the office or to superiors in a timely manner, this can be achieved through the use of an electronic charting system. With the right communication tools in place, information can easily and quickly be shared with clinical management and the entire care team.
Patient information that is transcribed immediately is not only more accurate than information transcribed well after the visit, but the information is then available for other members of your organization who need it for clinical management, quality assurance (QA) and billing. The primary clinician or case manager may know the patient well, but what about any subsequent caregivers who fill-in when the primary contact is off, out sick or on vacation? Up-to-date patient information also is beneficial for on-call staff, who benefit from the most recent information for a patient.
Lapses in clinical information and visit documentation certainly are not going to create improvements in agency efficiency or patient care.
Pitfalls of selecting the wrong solution
While it may be tempting to jump into point-of-care charting at your organization, the decision to do so must make sense. Explore the possible efficiencies and benefits of the technology, but remember these obvious but often overlooked criteria that might be signs of a troubling implementation of the technology:
- Your new point-of-care solution can’t take away from patient care. This may be obvious, but it can’t be overstated. If clinicians can’t hold a conversation, make eye contact or truly engage the patient that means you may be losing much of the efficiencies the system is supposed to create. You may have streamlined your processes, but you may be sacrificing quality patient care at the same time. Your solution must be easy to use, enhancing care while not taking away from it.
- Electronic charting cannot be cost-prohibitive. The cost of software, hardware, connectivity and maintenance need to be considered during project assessment, obviously. In many cases, the cost can be as little as $1 a day per patient; however, if your solution requires a complete laptop, is a data hog or routinely freezes up and loses data, these costs can quickly escalate, possibly leading to a financial burden for the organization.
Making the move to electronic documentation at the point of care is not a decision to be made lightly. If you do decide to make the move, do your due diligence and make sure your chosen solution drives your organization forward toward the desired goals. Doing some pre-implementation preparation goes a long way toward improving outcomes for the long term.
If you would like to know more about how to choose a proven solution, DeVero can help you best understand how to empower your home health agency.