Before Using Your EHR for Endoscopy Procedure Documentation,
Know What Questions to Ask
Using Your EHR for Physician Documentation May Create Unforeseen Pain Points
Healthcare facilities are always looking for ways to streamline workflows and simplify processes. They want to do more with less, i.e. with fewer software solutions. Because of the significant investments already made in electronic health record (EHR) system, healthcare executives often want to rely on EHRs for nearly everything - including clinical procedure documentation. And EHR companies have taken notice of this demand, often touting an "all-in-one" or "one-stop-shop" solution, even though many EHR clinical modules may be inefficient or incomplete.
To ensure you choose a clinical procedure documentation solution that enables physician satisfaction, efficiency and quality of care, be sure to ask potential vendors these nine questions before making any decisions.
Can we start documenting procedures immediately in the EHR? What content and functionality is available "out-of-the-box"?
Why it's important to ask
Some EHR procedure documentation modules only offer basic content "out-of-the-box." They require you, the customer, to build out and maintain the majority of the content. Building out this content for all the procedures (filling all picklists, templates, ICD-10 diagnosis codes and CPT® reimbursement codes) is a very detailed and time-consuming process that can take one or two full-time analysts and years of work. Then, once the solution is content-ready, an analyst will be needed to maintain the content.
The Provation advantage
Provation implementation is smooth and fast - with minimal case load disruption. That's because highly vetted, deep medical content and reimbursement coding comes standard with Provation solutions. Best yet, Provation maintains this content and coding for customers through frequent software updates.
Does the EHR documentation solution automatically generate accurate reimbursement codes and apply them to the procedure note?
Why it's important to ask
When documenting procedures in your EHR, the module may offer you available reimbursement codes to choose from once the procedure is selected. However, physicians would still need to manually select the appropriate codes from the set of available codes under that procedure.
As mentioned, it is possible the EHR vendor will require you, the customer, to build and maintain ICD-10 and CPT® codes. In which case, the availability and accuracy of the codes will be dependent on your site, not on the vendor.
The Provation advantage
Accurate, automatic coding comes standard with Provation software. The highest levels of specificity can be achieved with Provation because ICD-10 and CPT® codes are automatically added to procedure notes based on the physicians' selections. The result is a coder-ready note that enables more accurate billing and supports compliant reimbursement. Before e-signing, clinicians can verify the codes and adjust as needed. Best yet, Provation's coding experts keep these reimbursement codes up to date in the software, pushing out software updates regularly.
Can the EHR integrate with scopes and imaging devices?
Why it's important to ask
The ability to integrate with scopes and imaging is not guaranteed with EHR-based procedure documentation solutions.
The Provation advantage
Provation software is designed to integrate with virtually all endoscopes. This integration enables convenient native image capture, so your physicians can easily associate high quality images with their procedure note findings within Provation.
Does the EHR allow you to capture discrete data while creating procedure notes?
Why it's important to ask
Discrete data capture, or the ability to gather very granular data so that it can be measurable and reportable, is often not possible when documenting procedures in EHRs. Typically, healthcare professionals create procedure note templates in the EHR, which fall short because physicians resort to using free-text for most procedure details. That means the procedure data cannot be easily extracted to support benchmarking, quality reporting or clinical research.
The Provation advantage
Provation is renowned for its discrete data capture capabilities. The clean structured data in Provation supports data reporting, analytics, quality registry participation and clinical research. Unlike with EHR procedure documentation, Provation's discrete data allows doctors to conduct high quality research and as a result, Provation is cited abundantly in academic medical journal articles.
Does the EHR offer image capture functionality?
Why it's important to ask
Image capture functionality, or the ability to capture images within the software without toggling between devices and software, is an advanced feature that may not be available or optimized in an EHR module. This means that procedure images must be captured and stored using another program or system, separate from the procedure note. These images can later be uploaded and associated with the procedure note; however, it leaves more room for human error, misplaced files and data security risks.
The Provation advantage
Unlike with many EHR modules, native image capture comes standard with Provation software and it's definitely a physician favorite. The clinician simply opens the patient's procedure note in Provation, captures all images during the procedure, and associates high quality images with their procedure note findings and anatomical diagrams within a matter of seconds.
Does the EHR have a physician-friendly workflow for procedure documentation?
Why it's important to ask
Although the majority of physicians say EHRs improve the billing process and communication among physicians and staff, only about half of physicians think EHRs improve patient care or clinical workflow, according to a 2019 study. That's likely because EHRs are often built as a one-size-fits-all solution for an organization, regardless of the specialty or workflow.
The Provation advantage
Provation is recognized as a leader in the endoscopy market for its ease of use because of its anticipatory user interface. Designed specifically for procedure documentation, Provation quickly guides clinicians through deep medical content to capture all relevant procedure details by anticipating their most logical selections.
The resulting Provation procedure note is a high quality, medically accurate and timely output that supports immediate communication from the specialists to their colleagues and primary care physicians to support the continuity of patient care.
Can nurses, techs and other clinical staff members contribute patient data to the physician's procedure note when documenting in the EHR?
Why it's important to ask
There may be limitations in the EHR procedure documentation module's roles and permissions, limiting procedure note data and access to only the physicians. It's possible that nurses and techs will see different screens and menus when they login, limiting their ability to import images, specimen data and other patient information into the procedure note.
The Provation advantage
Although Provation software is designed for physician documentation, it enables nurses, techs and other members of the care team to contribute patient data and images to the procedure note. This allows efficient, streamlined workflows that don't rely so heavily on physician desk time.
Does the EHR documentation module have medical content to support advanced or complex procedures?
Why it's important to ask
Complex, advanced procedures are not only the most difficult to perform, document and code thoroughly and accurately, they are also the most difficult to create documentation solutions for. Make sure the vendor has done its due diligence to build out the medical content that's necessary for your facility's procedures (beyond just the basics), and that their solution makes it easy for physicians to access this information during documentation.
The Provation advantage
Provation procedure documentation software offers physicians quick and easy access to deep medical content, even for complex gastrointestinal (GI) procedures. Designed and maintained by industry-leading physicians, coders and medical content specialists, Provation is renowned for its physician-friendly workflows and comprehensive clinical content library.
How does the vendor manage software updates for documentation?
Why it's important to ask
The EHR vendor will likely provide occasional software updates to resolve technical issues and maintain some or all of the built-in functionality. However, they will not provide support or software updates for anything that you, the customer, builds within the module. Therefore, if the customer is responsible for building the majority of the content, any updates to that content is also the responsibility of the customer. This can require full-time analysts for ongoing content monitoring, updating and staff communication.
The Provation advantage
Provation's medical content is closely monitored by a team of experts. Consistent Provation software updates and customer support are always available.