We’ve all had tasks at work that we absolutely dread. For doctors, that task is often documenting patient care to the meticulous specificity required. Documentation is under growing scrutiny as healthcare continues to move toward value-based care. But in this day in technology, it’s never been easier. In this guide, we’ll look at what it takes to improve patient care with AI.

Upgrading healthcare efficiencies

Having accurate clinical documentation can “actually improve physicians’ baseline performance. This helps physicians rank higher among their peers. However, many physicians are frustrated. They struggle with “being sidelined by a clinical documentation specialist on their way to the bathroom or the cafeteria or in the elevator.” The need for the documentation is clear. Yet physicians find requests for more patient data to be a drain on their time.

Enter artificial intelligence (AI).

Hospitals are putting AI tools to work. These tools will ensure clear, complete, and compliant documentation is available. They’ll also free up some of the frustrations physicians face. But AI is a broad category.

Let’s take a look at 4 branches of this digital tree:

1) Natural language processing

Natural language processing (NLP) involves intelligent analysis of written language. Much of a CDI specialist’s time involves analyzing physician documentation. If a discrepancy is found, the specialist is responsible for questioning, or querying, the physician to ensure care is accurately documented. This process is cumbersome for both, as significant amounts of time are spent retrospectively analyzing a patient’s chart.

doctor writing on patient's chart

But with NLP, healthcare organizations can eliminate “the need to have clinical staff read through medical notes.” They can also automate many of their documentation processes and “reduce what could take days into a matter of minutes.”

2) EHR with voice recognition AI technology

As seen with Siri, and Alexa, voice is a popular data input option. And electronic health records (EHR) platforms are taking note. The struggle currently surrounds accuracy rates. Although a notable way to increase efficiency, a 2018 study still found a 7.4% error rate for clinical documentation generated through voice recognition tools.

Facilities such Concord Hospital are seeing substantial improvements surrounding provider satisfaction rates though. “In the previous world, clinicians had to write an immediate post-op note,” according to Concord Hospital’s CMIO Paul Clark, M.D. “Then they’d come back later and dictate a note. Now, they use templates that allow them to dictate their post-op note, and it also functions as their operative note, so they’re not doing it twice.”

3) Machine learning

A 2000 study looked at the medical literature reading habits of internists. The researchers found that survey respondents spent just over 4 hours a week reading the latest medical research. They also noted respondents relied “heavily on abstracts and pre-screening of articles by editors.” Those respondents reported reading only the abstracts of 63% of articles.

There’s no doubt the rate medical literature is produced has increased since that study. That makes it easy to understand why it’s challenging for medical experts to stay up to date. Machine learning, a technology that can be used to “improve the answers with feedback, training, and repetition,” may be just the digital solution needed. It can help them by supporting their decisions, improving outcomes, and reducing costs.

4) Computer assisted physician documentation

With computer assisted physician documentation (CAPD), physician documentation is analyzed to provide real-time feedback and to help resolve inaccuracies. This AI enabled tool allows healthcare professionals to spend more time providing care and less time checking documentation.

It also empowers CDI specialists. They can streamline manual processes, review charts for medical errors, clinical indicators, diagnosis, and procedure details, and suggest documentation improvement opportunities.

Recognizing the burnout 

According to Medscape’s 2019 National Physicians Burnout & Depression Report, more than 40% of physicians are burned out. Notable – and relatable – responses include:

  • 59% of respondents reported having to deal with too many bureaucratic tasks
  • 34% reported spending too many hours at work
  • 26% reported feeling less motivated to be careful while taking patient notes
  • 14% reported making mistakes they would not have otherwise made as a result of burnout

We know that physicians are often spending more time looking at screens than they are with their patients. And we know that AI can alleviate some of that. However, not everyone is sold on the idea of outsourcing human tasks to AI and machine learning.

The struggle to trust technology to accurately record and analyze data is likely at the heart of current adoption challenges. Such challenges are expected to transform with time. But one question remains: at what point will human interaction become less important than AI technology?

female doctor closeup

Balancing the digital with the human experience 

In 2018, 71% of Americans believed AI will eliminate more healthcare jobs than it creates. That same year, Babylon Health announced that an AI algorithm scored higher than humans on a written test used to certify physicians in the UK.

But a delicate balance will likely always be needed for effective health care. In fact, most AI experts believe that a blend of human experience and digital augmentation will be the natural settling point for AI in healthcare.

CDI departments may benefit the most from adopting AI. Leveraging the speed of technology will help to maximize productivity as well as highlight and prioritize opportunities for improvement. With staffing shortages translating to decreased financial impact, AI creates an environment where more charts can be reviewed. They may also potentially require less CDI staff.

Looking down the digital road 

Physicians and CDI specialists must stay abreast of AI in healthcare. They can indeed improve patient care with AI. Human involvement will remain essential to care, but the future of care may very well rest on digital shoulders.

Change is coming. How is your organization preparing for it?

“When you walk to the edge of all the light you have and take that first step into the darkness of the unknown, you must believe that one of two things will happen: there will be something solid for you to stand upon or you will be taught to fly.”

–Patrick Overton

We’re here to empower you

Harmony Healthcare’s Clinical Documentation Improvement solutions support your organization with interim expertise optimize reimbursements and prevent future denials.

Discover how our solutions can help your organization:

  • improve clinical documentation to mitigate lost revenue and retain future revenues
  • identify clinical documentation and revenue integrity opportunities for optimal reimbursement
  • streamline the CDI process with robust analytics and automated worklist triage for improved efficiencies and optimized reimbursements

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