4 tips to ease EHR documentation struggles and boost satisfaction

Physicians are tired. Burnout is real. In fact, burnout has been a major problem affecting clinicians for decades, and COVID-19 exacerbated those feelings. And the complexity of EHR documentation isn’t helping.

According to the Journal of the American Medical Informatics Association (JAMIA), excessive EHR documentation requirements and inefficient EHR utilization are significant contributors to clinician burnout. Among the 743 physicians who were surveyed across specialties, the leading causes of dissatisfaction included excessive documentation requirements (57 percent) and staffing challenges such as retention, shortages, and finding qualified talent (51 percent).

Here are four tips to help physician practices improve clinical documentation and achieve higher levels of ambulatory EHR satisfaction.

1. Tailor charting capabilities

To start, ambulatory EHRs should customize the ability to document and view patient data over time, based on unique documentation and billing requirements of that practice. This ensures providers view only what they need from the system. In my experience, therapeutic injections and medication compliance are two important examples.   

For ophthalmologists, therapeutic injection documentation includes location, procedure type, and physician name in the injection log list. EHRs configured to automatically calculate the number of injections, date of each injection, injection interval, visual acuity, and the number of weeks since a patient’s previous injection support a more streamlined charting process and deliver greater physician satisfaction.  

With digital insights into a patient’s medical history and multiple data files, doctors and clinics are better equipped to treat patients and meet their expectations. This readily available and valuable data streamlines time-intensive processes and contributes to easier clinical decision-making. 

2. Use detailed communications to engage patients 

Specific printout directions and summaries for the patient to take home are invaluable for continuing care. Detailed communications with patients encourage them to remain motivated and active participants in their plan of care. This leads to better outcomes, prompt care delivery, and cost and time savings.

For patients with an anesthesia allergy or intolerance, detailed documentation is imperative for follow-up providers to ensure safe and tailored procedures in the future. The same goes for the patient. The more a patient understands their health journey and the better educated they are about it, the better their chances of complying with the recommendations made by their provider.

Creating documentation efficiency and charting accuracy gives physicians more time with patients.

3. Keep staff trained and knowledgeable on EHR documentation

Specialty practices continually evolve. New treatments, advanced medications, and innovative therapies are frequently introduced. To deliver quality care, specialty practice staff and EHR systems must keep up with these changes.

Proactive system enhancements accompanied by staff training are paramount to EHR success. Here are three strategies to consider:

• Conduct training as new documentation features are introduced to ensure high levels of staff engagement and productivity.
• Clarify all integration points between clinical documentation and the group’s practice management system with the practice team to drive compliant billing, better manage appointments, and track patient flow.
• Consider dedicated training for staff with specialty practice expertise to provide ongoing staff training and education.

4. Ensure compliance

The healthcare regulatory environment is constantly evolving, and many specialty practices struggle to keep up with new coding, billing, interoperability, and quality reporting requirements. A compliant EHR that incorporates regulatory changes such as the 21st Century Cures Act, new CPT codes, and E&M guidelines, as the physician enters patient data into the system helps practices limit compliance shortfalls.

Simplify the complex

EHRs should be designed to assist and not hinder. According to a HealthIT.gov report, 88 percent of provider responders felt that their EHR helped them achieve clinical benefits for the practice. For specialties, consider options to reduce errors, improve patient safety, and support better patient outcomes in the practice setting by supporting the physician and their workflows.

Healthcare will continue to evolve, and the coming decades will likely bring unprecedented transformation. That said, one thing is for certain in uncertain times. When specialty providers have immediate access to complete and accurate information, providers and patients are empowered, and patients receive better medical care.

With over 15 years of experience in ophthalmology, Dr. Jason Handza, Nextech System’s Chief Medical Officer, is also a partner at Sight360 in Palm Harbor, Florida, and director and principal investigator for their Clinical Research Center in Pinellas Park, Florida.