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Capgemini

Clinical documentation is often viewed as a necessary evil: a cause for overtime work, an incomplete patchwork of irrelevant or out-of-date data, or a task done to avoid legal or regulatory consequences. In this section, we make the case for designing, building, and implementing automated clinical documentation according to a new paradigm, one with the power to transform clinical practice and yield major benefits to health care organizations, clinicians, and patients.

Contents

The Clinician's Perspective

The Role of the Executive

Moving From Manual to Automated

The Future Is Now

The Clinician's Perspective

The health care industry is under intense pressure to improve the quality and consistency of the care it provides. Though many safety advisors have suggested automating functions, such as physician order entry, as part of the solution, few have understood the central importance of automating clinical documentation, nor the need to integrate these two functions to achieve real interdisciplinary benefits.

"The nation's current health care system often lacks the environment, the processes, and the capabilities needed to ensure that services are safe, effective, patient-centered, timely, efficient, and equitable." ¹

Reinventing Clinical Documentation

The Institute of Medicine's (IOM) 2001 report, "Crossing the Quality Chasm," told clinicians what they already knew: The nation's current health care system badly needs improvement in terms of the safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity of the care it provides patients.

The health care work environment is not only unsafe for patients, it is unsafe for clinicians. Clinicians find themselves overworked and stressed to the point of being unable to care for patients in the way they've always wanted to. They are healers, but the environment in which they now practice medicine is unsafe rather than healing, and many feel powerless to do anything about it.

The IOM report also noted something clinicians may be less aware of: "… carefully designed, evidence-based care processes, supported by automated clinical information and decision-support systems, offer the greatest promise of achieving the best outcomes from care for chronic conditions."

In other words, clinical documentation — automated and reinvented — offers significant opportunities for improving the environment and methods of clinical practice. The framework, technologies, and work processes for realizing these opportunities exist in the marketplace and are ready for implementation.

For many clinicians, this may come as a surprise. Clinical documentation has long been the bete noire of clinical practice. With its plethora of forms and formats, clinical documentation takes precious time and attention away from caring for patients. In their admirable quest to improve health care, JCAHO (The Joint Commission on Accredidation of Healthcare Organizations) and other regulatory bodies have added regulatory and documentation requirements. Responding to these new rules, clinicians have overreacted — fearing malpractice litigation and regulatory noncompliance — by spending many more hours and millions of dollars over-documenting.

To use an old '60s phrase, clinicians have viewed clinical documentation as part of the problem, not the solution. The prospect of automating this "necessary evil" doesn't make clinical documentation any more appealing to most clinicians, especially to those who aren't computer literate. Won't this new system take still more hours to learn? And the truth is, they are right: If an organization simply automates their current documentation practices (i.e., forms), they will most likely increase the time clinicians need to document care.

Clinicians might wonder, then, how clinical documentation can help solve the problems that up to now it has only aggravated? The answer lies in reinventing clinical documentation with a new patient-and clinician-centered paradigm.

A New Patient- and Clinician-Centered Paradigm

Automating clinical documentation so that it helps improve the quality of care from a clinician's perspective is much more than, and completely different from, simply computerizing an existing paper system. Computerizing a bad paper system only surfaces its shortcomings and makes things worse. Just computerizing a good paper system won't lead to improvements for clinicians and patients that make a difference. Automation must strike a new path.

Automating clinical documentation in this new way requires conceptualizing the role of clinical documentation in providing care according to a new paradigm. This paradigm must be understood and adopted by an organization before any productive automation can take place. Well before new software is designed or computers installed, one must think in a new way.

What are the hallmarks of this new paradigm? Here are some key guiding principles. Clinical documentation systems should:

Build a Coherent Patient Story

Clinical documentation systems must build and present a coherent patient story — a story unique to one patient — across the continuum of care received. Instead of being a collection of disassociated forms, clinical documentation must build a story in partnership with the patient that includes the evidence-based, patient-specific care given as the patient moves through the system. Documentation must keep the focus on the patient, not the forms or the data.

Empower Interdisciplinary Care

Clinical documentation systems must keep the members of the interdisciplinary clinical team informed of the care the other members are providing. Given that clinicians have less and less time with patients, documentation must enable clinicians to build on each other's contributions and expertise without duplicating efforts or capturing redundant data. Because no one clinician has all the expertise a patient might need, clinical documentation must empower the interdisciplinary team to provide care as a team, not as separate and distinct disciplines and caregivers.

Support Integrated Scopes of Practice for All Clinicians

Clinical documentation must support defined scopes of practice that clarify the responsibilities, competencies, and evidence-based knowledge for which each member of the interdisciplinary team is accountable. Scopes of practice must be integrated so that team members understand the responsibilities of others and trust each other to fulfill their responsibilities to the patient. No one should worry about having to redo work others have done.

Provide Evidence-Based Information at Point of Care

Clinical documentation systems should provide clinicians with the latest, relevant evidence-based information at the point of care. Evidence-based information should enable clinicians to provide consistent care within their defined scope of practice. But evidence-based information cannot simply be provided; it must support, and contribute to, patient-specific plans of care. Clinical practice guidelines take evidence-based information, combine it with individual patient data, and relate it to the individual patients.

Put Accurate, Concise Patient Data at Fingertips

Clinical documentation systems should enable clinicians to capture concise patient data at the point of care (for accuracy and time-savings) and view only relevant data in the most useful form for them at the point of care.

Reduce Duplication, Errors, and Complications

Clinical documentation systems should prevent duplication and errors in care. They should eliminate time-wasters that irritate patients (repetitive testing and information gathering, for example) and help clinicians prevent complications by catching symptoms in their early stages.

These guiding principles constitute a holistic framework for understanding the role automated clinical documentation can and should play within the healing environment. Indeed, this framework is fundamental to creating and sustaining a healing environment for patients and clinicians alike.

The Benefits for the Clinician

When clinicians view automated clinical documentation through the lens of this new paradigm, it looks completely different from the old clinical documentation they've known. Suddenly, they see a tool that can help them achieve the two goals they've always wanted to achieve, but never thought they could: better care for patients and a healthier practice environment for themselves. Now, for the first time, clinicians can have information at their fingertips to:

• Help them deliver safer patient care
  
• Make their workflow more efficient
  
• Provide consistent, competent care supported by evidence-based guidelines
  
• Get a comprehensive, up-to-the-minute view of the patient at the point of care
  
• Modify patient care and workflow based on measurable outcomes
  
• Communicate more effectively with other clinical team members
  
• Reduce redundant efforts, errors, and omissions
  
• Document more efficiently, accurately, and with greater relevance

Clinicians want to do the best job they can in the face of often overwhelming demands. They need the best resources — tools, technologies, and processes — to do it. Automated clinical documentation is the one tool that has the power to touch and enhance virtually every point of patient care. It can impact both patients' health as well as clinicians' lives.

The Role of the Executive

Is your organization’s clinical documentation system a necessary evil or a strategic asset? Many executives would answer reflexively “a necessary evil.” This is not only unfortunate, it is unnecessary. Our experience with forward-looking health care organizations shows that new approaches to automating clinical documentation can help transform health care organizations into market leaders – providers and employers of choice in their market areas.

Clinical Documentation: A Key Strategic Asset

Executives dismissive of the strategic value of clinical documentation often justify investments in physician order entry and medication administration with "hard dollar" ROIs measuring reduced costs and medication errors. Where is the equivalent ROI, they ask, in automating clinical documentation? Is it in reduced paper usage or lower personnel costs?

We believe they are asking the wrong question, or asking it in the wrong way. To understand why, it is useful to look closely at the critique of our health care system contained in the 2001 IOM report, "Crossing the Quality Chasm." Clearly stated, but frequently overlooked, is the report's finding that the number one threat to patient safety is not medication errors, but complications, duplications, and omissions of services by clinicians. Clinicians, particularly nurses, are the 24-hour providers of patient care. When they don't have the right tools, work processes, and information to care for patients, patients suffer, and clinicians grow frustrated and stressed. The consequences for the organization can be serious as well.

The right approach to automating clinical documentation provides clinicians with the technological and process support to dramatically reduce complications, duplications, omissions, and knowledge-based errors. As pointed out in the previous article, automated systems put critical patient data and evidence-based information at the clinician's fingertips at the time and place it will do the most good for the patient: at the point of care.

A New Look at ROI

When executives talk about the potential ROI of automating clinical documentation, the discussion frequently focuses on trying to calculate savings from reduced paper usage or reductions in overtime. This is the wrong approach because it ignores the full range of actual and substantial benefits that automation can bring to health care organizations. What would the value be to your organization of:

• Prevention of complications?
  
• Interdisciplinary integration at point of care?
  
• Evidence-based practice patterns?
• No duplications and repetitions?
  
• Better patient outcomes?
  
• Increased clinician job satisfaction?
  
• Improved clinician recruitment and retention rates?
  
• Decreased nursing overtime?
  
• Fewer coding errors and omissions?

While cutting back on nursing staff or reducing paper use might reduce costs, it will do nothing to improve patient care or any of the other outcomes listed above — all equally, if not more, important benefits of automation. These are the real ROI measures from automating clinical documentation.

Four Guidelines for Implementation

Once executives decide to automate clinical documentation, they must do it the right way for it to yield the promised benefits. Here are four guidelines that can make the implementation more successful.

Lead the Charge and Stay Involved

If you believe in the quality, satisfaction, and financial benefits of automating clinical documentation, you must lead the implementation effort and stay involved in the process to the end. Staying involved is important because automating your clinical documentation system will take a lot of time and effort to do right. Don't let the process slow down or stray from your stated goals.

State Your Goals Clearly

State your organization's goals for automation clearly, so you'll recognize success when they are achieved. Would you like to prevent complications and reduce variability? Stop duplication and redundancy? Increase clinician retention? Improve patient outcomes? Reduce nursing overtime? All of the above? Your goals for automation should be aligned with your organization's strategic goals to ensure that everyone in your organization is pulling in the same direction.

Make Sure Your Clinicians Own the System

The clinicians must drive automation of clinical documentation because they are the ones who will use it. The new system must improve their lives and reflect their needs and priorities, not those of the IS department. The clinicians are the customers. Challenge them to develop a system that will improve documentation and thereby improve patient care outcomes, professional growth, and their work lives. Don't let them automate the way they have "always done it" simply to stay within their comfort zone.

Choose the Right Vendor

Select a vendor whose systems support your organization's goals for automation. If your focus is acute care, choose a vendor that has developed systems for acute care units. Make sure the vendor's software functionality aligns with your goals and the vendor is willing to work with you and your clinicians to maximize and expand functionality. Don't force your clinicians to change the way they document in order to accommodate the software. Your clinicians should be the focus — and have a major say — in selecting a vendor. Equally important, find a vendor who will be your partner on this journey. Just as partnership among the disciplines enhances automation, so too will a partnership with your vendor.

An Enterprise-Wide or Departmental Solution?

Should one choose an enterprise-wide clinical information system that can be customized to meet departmental needs? Or should one allow departments to purchase their department-specific systems?

At the core of most enterprise clinical information systems are three tightly integrated components: physician order entry, clinical documentation, and the medication administration record. While these core components cover most of a hospital's information requirements, some departments, such as obstetrics, have unique needs related to their specialized devices and the integration of data from these devices into a patient's record.

Although many enterprise systems can be customized to meet the informational needs of these departments, these capabilities have to be built. Moreover, even when an enterprise system is customized for a department, it generally lacks key features critical to the department's functioning. These features are included in a department-specific system. For example, a dedicated obstetrics system will have mother-baby link, Friedman Curve/labor graph, fetal monitoring strip documentation, and fetal monitoring archival systems capabilities, while a customized enterprise system may not.

Simply buying department-specific systems, however, is not necessarily the answer. Though most vendors of department systems will tell you that their systems will interface with enterprise-wide systems, it is important to find out exactly what "interface" means. Often, it means that the department system can receive information from the enterprise system. But it may not be possible to flow the information the other way, from the department system to the enterprise system. Thus, if a woman is first admitted into obstetrics, for example, the patient's obstetrical events may never flow into her lifetime medical record in the enterprise system. And in systems where obstetrical data is sent to an enterprise system, it is currently sent as a document instead of being entered into a vital-sign flow-sheet for the purposes of trending data during the patient's stay.

Adding to the complexity of the enterprise-department dilemma are the specific legal and regulatory requirements that some departments, like obstetrics, must meet and their clinical information systems must support.

Lesson? Until enterprise systems are sufficiently robust to meet all the specialized needs of different departments, there is no easy solution to the enterprise-versus-department system dilemma. Organizations must understand the pros and cons of each and the often hidden intricacies of integrating them.

Automate for Tomorrow, Not for Today

Automating a clinical documentation system should mean thinking about the role of documentation in new ways. This rethinking opens up new opportunities for achieving important practical goals (for example, more accurate data entry and enhanced critical thinking and decision making) and larger strategic goals such as patient safety and staff safety and retention.

Many executives' thinking is bound by the limitations of the present. This flawed way of thinking manifests itself in several ways. Watch out for these tell-tale signs:

Automating Paper Systems as Is

The best paper clinical documentation systems are severely limited, not only by paper, but also by the outmoded thinking and work processes lying behind them. For example, only one person can view a paper chart at a time, but an entire staff of clinicians can have ubiquitous, simultaneous access to electronic data.

This difference alone can have a major impact on work processes. When executives give a prospective vendor a script and insist that the vendor's system demonstrate that it can automate current practices, they are engaging in shortsighted thinking. Automating should mean improving your clinical documentation and workflow. It should require rethinking and redesigning clinical work processes.

Using One Vendor for Everything

Some health care organizations are wedded to the single vendor model, using the same vendor for clinical systems that they use for billing or other financial functions. They believe that their IS department will have less trouble managing products from a single core vendor than from a number of different vendors. But this approach is often like wielding an axe to cut grass: The proper tool makes all the difference. When you select a clinical vendor, choose one with a well-designed, integrated interdisciplinary documentation system that will support your future, not just your current, documentation or IS needs.

Sticking to the Basics

Health care organizations no longer have to settle for just the basics (such as recording vital signs, admission assessments, and physical assessments). Though all applications originally provided just these basic functions, some systems now include advanced features (for example, scopes of practice and evidence-based information) that can transform your clinical documentation system into a strategic asset for your organization.

Automating the present is a dead end and a waste of your time and money. It is better to think about the clinical documentation system you will want in the future, and then use the automation process to create it.

Improving the Triple Bottom Line

Today's executives wisely view the bottom line as more than just profits. They factor other values into judgments about an organization's performance. By designing, building, and implementing automated clinical documentation according to the new paradigm we have described, organizations improve the "triple bottom line" — people, process, and technology. Patients and clinicians enjoy better conditions and outcomes. Work processes become more efficient and effective. Technology becomes a decisive factor in helping the organization achieve its strategic goals.

For health care CEOs, automation according to the new paradigm can mean:

• Preferred status as employer and provider of choice
• Improved clinician relations, retention, and recruitment
• Greater compliance through built-in regulatory standards
• Enhanced resource utilization and workflows with budgetary impact

In addition to these benefits, CNOs can look forward to:

• Greater patient safety and satisfaction
  
• Increased productivity and professional practice support through workflow efficiencies and evidence-based practice
  
• Healthier work environments
  
• Greater nurse-retention rates and job satisfaction
  
• IS-supported nurse recruitment
  
• Measurable patient outcomes
  
• New and improved physician-nurse working relationships

In today's highly competitive health care environment, executives need every advantage they can get. Automating clinical documentation is a powerful but often overlooked and misunderstood tool for becoming a market leader.

Moving From Manual to Automated

Let us say your organization has decided to automate its clinical documentation system. How do you know that the model product you plan to buy can be customized to meet your specific needs? How do you go about designing, building, and implementing it? What are the steps? What does an advanced clinical documentation system look like? What are the chief benefits you can expect if you do it right? What are the obstacles you are likely to face?

The Challenges of Automating

While most organizations, perhaps naturally, focus on the technologies of automation, it is the people behind the technologies — the clinicians — who hold the key to implementing automation and are its chief beneficiaries. Clinicians, however, are also likely to pose the greatest challenges and obstacles to implementation. Here are some of the challenges you may face:

Standardizing Clinical Content Based on a Common Vocabulary

Most clinicians work in a form-centric environment in which the disciplines gather their own patient data using their own customized forms. Taken as a whole, much of this data is overlapping, redundant, and irrelevant to the clinicians' primary purpose — caring for patients.

Automation addresses this redundancy and irrelevancy by replacing forms with access to patient information relevant to care. Different clinicians can view the information that is most relevant to their clinical competencies and duties (such as nursing and physical therapy) at any given time. Automating in this way requires that clinical content and information gathering be standardized and streamlined across departments. Burdening an automated system with all the existing forms from all the departments will only make automated documentation more time-consuming than it is on paper.

Nevertheless, many clinicians will find it difficult to give up their forms and will demand that the automated system deliver what they now have on paper. They must remember that a patient's respiratory rate or temperature is a piece of objective data and valid no matter which clinician obtained it. Data-gathering procedures should only be repeated if a patient's condition has changed.

Of course, automation will always have to provide the customized information required by some highly specialized departments (like neonatal). However, as a rule of thumb, only about 20 percent of an organization's clinical information should be customized, while the remaining 80 percent is standardized.

Changing Clinician Workflows

With automation, clinicians' workflow will change. Redundant tasks will be eliminated; new, patient-centered interventions will be added. Clinicians accustomed to working in "silos" will have to work as members of an interdisciplinary team, which may change both what they do and how they relate to each other. Nurses and doctors, for example, will work more closely as colleagues — with nurses providing doctors with information critical to patient care — thereby enhancing collaborative relationships.

Trusting Other Team Members

Clinicians accustomed to trusting only their own patient data will have to trust their teammates. Each discipline brings a unique perspective and expertise (scope of practice) to the task of caring for patients. Trust enables clinicians to build on each other's input, observations, assessments, and knowledge for the greater good of the patient. It leads to streamlined workflows, less duplication, and improved patient outcomes and satisfaction.

Entering and Accessing Patient Data in Radically Different Ways

With paper forms, one records and accesses data the same way. In an automated environment, clinicians will enter data differently than how they access it; the two formats may be dissimilar. The automated environment is a more flexible and efficient way of managing information, providing evaluation of structure, process, and outcomes in a way that a paper environment cannot achieve. However, clinicians must be flexible and open to change to make it work.

Implementing the New Paradigm

As we pointed out earlier, automation must be guided by a new patient and clinician-centered paradigm. How does one do this? In this section, we provide you with key steps for designing, building, and implementing according to this paradigm.

• Involve clinicians from all areas to guide and own the process. Decisions must be made by clinicians, not IS. Designing for automation is hard work, and it can be difficult to sustain clinicians' enthusiasm over the long haul. Therefore, the process must be rapid so that enthusiasm and momentum are maintained. While clinicians may believe in the theory of automation, they will only become enthusiastic disciples once they can put the system to work. The proof of the pudding is in the tasting.
• Standardize clinical content to eliminate redundant documentation and have all clinicians use the same vocabulary.
• Consider the impact of using standardized, pre-configured, evidence-based automation, instead of building from scratch. That is, how would buying and modifying a system with existing, evidence-based content change your process? Not having to reinvent the wheel can markedly speed things up, and all organizations may, in the future, opt for this rapid design approach.
• Design common data elements that can be shared by inpatient, outpatient, and emergency departments
• Build triggers into the system that alert departments to patient needs based on documentation
• Design discharge planning/disposition documentation to include interdisciplinary input
• Standardize and achieve consensual agreement on documentation content so that information can be shared among inpatient applications
• Design documentation that supports service delivery and uses charting by exception
• Design workflow tools such as task lists and clinical dashboards to support clinicians as they provide care
• Design appropriate links between documentation and orders so that a clinician's workflow is enhanced rather than encumbered
• Draft new policies and procedures governing the new documentation paradigm
• Identify measurable indicators of success that demonstrate the system's effectiveness

What Should an Automated System Do?

An automated clinical documentation system enables fast, efficient, and accurate data collection — including the automation of complex and tedious calculations previously done manually or with multiple steps — and facilitates information-sharing and collaborative processes within and across clinical teams. As you will see, advanced, automated clinical documentation systems include much more than just clinical documentation in the traditional sense. An advanced automated system should provide the following:

Clinician Dashboard

The clinician dashboard, configured to clinicians' workflows by role, location, or personal preference, provides clinicians with notification of new orders, results, verification requirement of orders entered by ancillary personnel, isolation requirements, infectious disease history, and clinician assignments. The dashboard may enable remote access via the Web by specialty clinicians, such as case managers and transplant coordinators; multi-patient activity lists with all components of the plans of care; and access to interdisciplinary health care issues, such as allergies, chronic health concerns and diseases, and current medications across all visits. The possibilities are virtually limitless.

Clinical Decision Support

The system should incorporate all interdisciplinary documentation and clinical data for generating clinician-specific rules, alerts, and reminders. It should be able to implement communication and escalation policies for alerts and messages to ensure action if acknowledgement is received within the time defined by the facility. These rules, alerts, and reminders should cover areas, such as infection control, restraint renewal, potential for injury, and nutritional risk.

Medication Management

Since the act of administering medications is the last opportunity to detect an error before it harms a patient, the system should provide clinicians with advanced error-checking capabilities at the point of care before medication is administered. An electronic medication administration report, generated in real time with order entry, should provide clinicians with times for drug administration and alerts for overdue drugs and location-specific scheduling and rescheduling. To prevent medication errors, the system should provide a "closed loop" between the medication order, the drug itself, and the patient.

Clinical Documentation

The system should not simply accommodate, but encourage interdisciplinary documentation — from health notes to flow-sheets — that can be individualized for each patient and can support multiple documentation methodologies. Clinicians from different disciplines must be able to contribute to the same documentation with the system capturing all of the appropriate dates, times, and signatures. Departments should be able to customize documentation tools to meet their distinct needs, such as mandatory fields or facility-defined dictionaries, while the system provides enough standardization to promote continuity of care across all departments.

Clinician Order Entry

The system should provide for order entry for all workflows, including physician entry, clerical entry with nurse and pharmacy verification, and verbal order entry with physician electronic signatures. It should also provide for direct entry of nursing orders, multi-signature authorization (such as chemotherapy orders), and clinical pathway ordering. When an order is placed, automatic links should make the appropriate documentation (a row added to the appropriate flow-sheet, for example, or an intervention added to a plan of care) immediately available to the clinician.

Evidence-Based Charting

To improve patient outcomes and safety and reduce variability in patient care, the system should provide clinicians with dynamic clinical practice guidelines at the point of care. These clinical practice guidelines should contain evidence-based, diagnosis-specific information created for an interdisciplinary team with integrated scopes of practice. Fully integrated into the documentation system, evidence-based charting supports critical thinking and outcome-focused care, generates problem-linked interventions, presents related information pertinent to decision making, and helps improve patient outcomes and clinician productivity. Evidence-based charting integrates a framework for addressing ever-changing regulations, such as JCAHO documentation standards, enforcing restraint policy, documenting pain management, and signing verbal orders.

What Are the Benefits of Automation?

Designing and implementing an automation system takes a lot of thought, work, and money. Are the benefits worth it? Experience says they are. Though we have touched on them already, here are some of the benefits of automating your clinical documentation:

• Improved patient safety and timeliness of care through alerts and rules triggered by documentation
• Increased patient and clinician satisfaction through fewer redundant activities, such as taking vital signs, asking questions, and documentation.
• Streamlined clinician workflows through intentionally designed tools, directly linked to documentation, that enhance process and outcomes. Tools such as patient's history, clinical practice guidelines, education/goals outcomes, and the like.
• Real-time access to patient data by all authorized personnel
• Enhanced real-time clinical decision making through specialty data views
• More accurate and complete charge captures through clinical documentation
• Reduced overtime spent on documentation

As you can see from the testimony of health care organizations that have implemented automation, its benefits are real.

What Automation Won't Do for You

The current state of advanced automation technologies offers remarkable opportunities for improving patient safety, outcomes, and satisfaction. It offers clinicians the tools to provide a higher level of care more efficiently and to achieve higher levels of job satisfaction for themselves.

As we have shown, the technology has progressed far beyond the basics to an advanced stage where it can make a major difference in patients' and clinicians' lives and in the health of the health care environment.

Yet, these technologies, as remarkable as they are, cannot supply the human element that makes these benefits possible. They can strengthen, but not create, the interdisciplinary relationships that make clinical teams work well together. They can convey, but not create, the integrated scopes of practice and accountabilities that guide clinical work. They can aid, but not perform, the critical thinking that is so important to improved patient care. And they can enable communication, but cannot provide the will to communicate or do the communicating.

Only clinicians committed to new ways of thinking, practice, and relating to each other can do these things.

Hardware and software limitations impeded automation in the past, but the technology has more than caught up with our dreams. Native Web-based technologies are robust, easy-to-use, less costly than before, and flexible. In particular, the move from "Web-enabled" to "native Web-based" technologies has dramatically lowered the cost, improved the ease of use, and enhanced the flexibility of current and future devices and applications. Access to a hospital's system from outside the hospital, for example, has been vastly simplified with native Web-based systems that significantly reduce the cost of development.

Native Web-based technologies easily adapt to future developments, making obsolescence less of a concern. While past systems were hardware or vendor-dependent, or dependent on expensive "middleware," today's Web-based technologies are hardware and vendor-independent. End-users won't be required to use a keyboard or mouse. As new end-user devices (handhelds, advanced cell phones, tablets, voice recognition) are developed, organizations will be able to adopt them, and clinicians use them, with little trouble, because the human and technological infrastructures will already be in place.

Imagine these scenarios:

• Clinicians receiving alerts anywhere via their cell phones
• EMT personnel photographing a wound with a cell phone from the ambulance and transmitting the image instantly to the emergency department and the patient's record at the hospital
• Clinicians taking blood pressure or responding to a code situation, and the system automatically and instantly documenting it in a structured manner
• Clinician drawings or photographs of a patient being made instantly available to all members of the clinical team treating the patient
• Clinicians having instant access to all team members' critical thinking about a patient without having to plow through unnecessary and irrelevant data
• Clinicians requesting "consults" by speaking into a voice-recognition system from anywhere inside or outside the hospital

These scenarios depict a health care environment in which an interdisciplinary team delivers care more quickly, efficiently, accurately, and with a greater focus on the needs of the patient. Most of the technologies required to make this environment a reality are available now.

The Future Is Now

Health care organizations contemplating automating their clinical documentation systems often ask three questions about the future: Is the technology ready now? How can we protect ourselves against instant obsolescence? How can we convince clinicians to learn a whole new way of practicing?

Meeting the Challenges of the Future

As attractive as these scenarios seem at first, health organizations can't be blamed if they react to this future with alarm. They are already looking down the barrel of a future loaded with so many challenges that adding a new one — implementing automated clinical documentation — may be the last thing they want to do. Clinicians, especially those who are computer illiterate or otherwise set in their ways, may be the least enthusiastic of all.

Nevertheless, if one examines this daunting task more closely, it becomes clear that our new paradigm for automating clinical documentation holds the key to meeting many of the challenges of the future.

Let us look at just one such challenge, highlighted by the 2001 IOM report. It is the call for evidence-based decision making. "Patients should receive care based on the best available scientific knowledge, and that care should not vary illogically." This recommendation will require clinicians to develop new skills, such as searching, appraising, and using research that will fundamentally change the way they practice in the 21st Century.

Executives and clinicians are understandably worried, even panicked, about meeting this standard. Locating and appraising relevant evidence, combining it with one's own expertise and experience, and then applying this mix to the needs of individual patients takes great skill and can be extraordinarily time-consuming. Assuming clinicians gain the requisite research and evaluation skills, where will they find the time? The Gartner Group suggests that clinicians would have to read at least 19 articles a day just to remain up to date in general medicine⁵. MEDLINE® has added more than 460,000 references over the past year alone.⁶

Our new paradigm for automating clinical documentation responds directly to the IOM's recommendations for making medicine safe. It enables clinicians to access, use, and customize to the needs of patient evidence-based knowledge at the point of care. For the first time, they will have the tools and information at their fingertips to provide the high level of care they always wanted, and will be now be required to, in order to meet the new legal, regulatory, and practice standards of the future.

For executives worried about how their clinicians will adapt to this computerized environment, it is worth noting that many young clinicians are graduating from school expecting to work in an environment supported by advanced IS technologies. This technology has been incorporated into their schooling and clinical training. Similarly, many working clinicians, familiar with the current state of the art in computing from their home computers, have been disappointed and perplexed by the primitive use of computers at work up to now. Therefore, all clinicians — computer literates and illiterates alike — will find automated clinical documentation a great boon to meeting the challenges of the future.

Figure 1: Screenshot — Example of a Clinical Practice Guideline

It's All About the Patient

To understand the new paradigm for automating clinical documentation, keep this one principle in mind: It is all about giving the patient the best possible care. This single-minded focus on the patient is often the most difficult aspect of this paradigm shift for organizations to assimilate. By comparison, installing technology is easy. By combining evidence-based knowledge with technology, the paradigm gives clinicians the tools to give patients better, more personalized care more effectively and efficiently than ever before.

In the previous articles, we argued that it is a mistake to become so enamored of the new technology that one expects it to solve all problems. When health care organizations simply automate their existing paper documentation systems, they fall victim to this mistake. Implemented in this way, even the best technology will only make matters worse by increasing clinicians' workload. Unless technology presents the right information to the right clinician at the right time and place, it adds no value.

What is true of technology, however, is equally true of evidence-based information. The best content will have little impact on care unless it is available at the right time, to the right clinician, and linked in a meaningful way to the problems on the plan of care for a particular person. Simply providing information, or generating a list of tasks, is not enough. Information must be integrated into a specific plan of care for a specific patient in a way that meets the various informational needs of the interdisciplinary team's members treating the patient. Clinical practice guidelines (CPGs), illustrated in Figure 1, accomplish this task by bridging. the gap between technology, evidence-based information, and the needs of an interdisciplinary team treating specific patients.

CPGs encompass evidence-based knowledge (derived from the literature and validated by expert opinion) goals and outcomes, potential complications, signs and symptoms, interventions, and general information. They are targeted to the scopes of practice of the interdisciplinary team and thus encourage the interdisciplinary treatment process. CPGs support clinical decision-making with evidence-based options from which clinicians can choose the most appropriate interventions for specific patients.

Most important to this discussion, clinical practice guidelines are intentionally designed to be delivered to clinicians via an automated clinical documentation system. They are an integral part of a framework of automated tools that help guide patient care and document care. Other such tools include patient profile and history, plan of care, patient care summary, and education/outcome record. When designed and implemented within this framework, automated clinical documentation supports the interdisciplinary team with the best information at the point of care, tailored to the needs of specific patients. In this way, automated clinical documentation provides clinicians with the clinical information and tools they need to deliver optimum patient care in the 21st Century

SPECIAL SECTION SUMMARY

Clinical Documentation: The Questions You Need Answered

As you can see, automated clinical documentation can be a powerful tool for achieving multiple goals for diverse health care constituencies. But automating the right way involves major organizational change, and a great deal of thought must precede the implementation of the technology if automation is to be successful. In short, one must think first and build second.The following is a summary by way of a checklist of points for executives to consider before, during, and after they embark on an automation project.

• Is your automation plan based on the new paradigm, or are you simply automating your paper system?
• Is your automation plan aligned with your organization's strategic goals?
• Are you prepared to provide clear leadership until the project is complete and up and running?
• Have you committed sufficient resources (time, money, and people) to design, build, implement, and maintain your new system?
• Have your clinicians bought into the new ways of thinking, practicing, and communicating that automation will require?
• Are evidence-based knowledge, interdisciplinary care, and integrated scopes of practice at the core of your automation plan?
• Are increased patient and clinician satisfaction among the primary goals of your automation plan?
• Will you be measuring the effectiveness of your new system in terms of improved patient outcomes (fewer duplications, omissions, and errors) and consistency of care?
• Does your organization have an informed perspective on the technical and organizational issues involved in selecting the right vendor?
• Does your prospective vendor's solutions offer the functionality you need?
• Can your vendor's solutions grow easily to accommodate new technologies as they come onto the market?
• Is your vendor willing to partner with you over the long term as your organizational and technology needs evolve?

Endnotes

1 Committee on Quality of Health Care in America. Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy Press. 2001.
2 Sackett, D.L., Stause, D.E., Richardson, W.S., Rosenburg, W., Haynes, R.B. "Evidence-Based Medicine: How to Practice and Teach EBM." London: Churchhill Livingstone. 2000.
3 Wesorick, B., and Hanson, D., "Clinical Practice Guidelines." Michigan: Practice Field Publishing. 2000.
4 Ibid.
5 O'Rourke A. Seminar 3: An Introduction to Evidence-Based Practice. www.shef.ac.uk/uni/projects/wrp/sem3.html.
6 U.S. National Library of Medicine. Documentation for Distribution of 2002 Baseline MEDLINE Database on DTL Tape and 2002 Update Files via FTP. January 7, 2002. www.nlm.nih.gov/bsd/licensee_2002/baseline_medline_doc.html.