KLAS: Clinical Documentation Strategies 2023

What You Should Know:

• For years, documentation has been a pain point that has led to clinician frustration and burnout, but numerous strategies have emerged to ease that burden and enhance patient care. COVID-19 has exacerbated burnout, leading organizations to renew their focus on improving documentation.
• A new report by KLAS examines physician-facing documentation technology and services, along with how vendors compare in overall scores, and the key performance metrics of value and outcome.

Key insights on Clinical Documentation Strategies in 2023

Over the last three years, healthcare organizations have seen increased employee attrition, heightened levels of physician burnout and dissatisfaction, and increased costs that have squeezed already tight profit margins. As a result, outcomes and value are top of mind for provider organizations as they consider their documentation strategies, even taking precedence over technology consolidation, which is a focus for organizations in many other areas. The outcomes that are most frequently commented on include improved dictation accuracy, increased capture of billable issues, correctly identified and coded encounters, reduced time spent preparing and reviewing documentation, and improved documentation closure times to decrease outstanding A/R days.

The most crucial findings from the report are as follows:

1. Ambient Speech Recognition: Technology Rapidly Growing and Showing Initial Promise: While there are a few vendors that either employ or are working on ambient speech technology, this is still a newer market that is not yet fully measured by KLAS.
2. Front-End Speech Recognition: Becoming the Go-Forward Platform for Documentation: Provider organizations report that the overall market is moving toward speech recognition as the go-to documentation platform. Respondents feel that speech recognition has improved over the last couple  of years in its accuracy and ability to detect accents, at least to the point that it is on par with the accuracy seen in transcription.
3. CAPD: Organizations See Benefits, but Physician Buy-In Remains Low: Almost all respondents mention the benefits of CAPD; the real-time nature of CAPD enables more efficient code capture and therefore improved revenue and reduced documentation time. Still, adoption among physicians is proving to be a challenge for a few reasons. Some provider organizations using CAPD solutions cite inaccurate or erroneously fired recommendations.
4. CDI: Technology Drives Results, but Development Has Been Slow: There is currently wide adoption of CDI in the inpatient space, and there is significant growth of CDI in outpatient care. Even so, provider organizations feel that development of CDI software overall has stagnated. An exception to that may be Iodine Software, who respondents see as a highly innovative company.
5. Transcription Services: Adoption Decreasing, but Still a Valuable Part of Provider Workflow: Respondents feel that transcription will continue to play a limited but important role in documentation. Transcriptionists and scribes have been especially useful as an aid for physicians who are hesitant to adopt speech recognition technology and as a backfill for organizations with large documentation backlogs. The transcription market has recently seen a lot of change, as AQuity Solutions has spun off from MModal after being acquired by 3M, and as DeliverHealth has acquired Nuance’s transcription services arm. As a result of these changes, respondents feel that their relationships with their firms have suffered slightly. Client satisfaction with executive involvement, proactive service, and communication have all recently declined somewhat.
6. Virtual Scribes: Still Having Highly Positive Impact, though Replacements Cause Inconsistencies: 94% of respondents feel that their virtual scribe has a positive or highly positive impact on their documentation time, and most mention that their documentation is completed by the end of the day. Provider organizations are most likely to recommend using a virtual scribe as a bridge to help achieve same-day closures when physicians are having difficulty closing their notes in a timely manner. 

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