The Healthcare Data Imperative

Transforming Healthcare Through Support of Clinical Documentation

By Terri Mitchell, MSN, RN
Director of Clinical Informatics Solutions, Nuance Healthcare

In today’s healthcare environment, healthcare organizations and clinicians are under extreme pressure to lower costs while improving quality, safety, and outcomes.

What is the common and constant theme within key initiatives? Data. This strongly supports making the case for investing in solutions that facilitate the improved ease and capture of data to provide a comprehensive clinical story, the ability to access and use that data for the coordination and collaboration of evidence-based care delivery and the need to leverage it for Clinical Decision Support (CDS), Real-Time Surveillance, reporting and performance improvement initiatives.

The processes and solutions necessary to support the documentation of clinical care intersect with many initiatives related to patient care, informatics, workflow, research, quality, and reimbursement. Therefore, the role of clinical documentation improvement has taken on a critical importance. Capturing data efficiently and effectively, preferably at the point of care, while making data informative, meaningful, and actionable is imperative for the delivery of safe, quality, and cost-effective healthcare. The quality and completeness of the documentation created by clinicians affects every person and process throughout the continuum of care. It is what fuels the patient encounter, future encounters, patient experience, care delivered, and ultimately the final reimbursement for that encounter.

While clinical data holds enormous potential, that potential cannot be realized, nor can investments in EHRs and other information technology tools be capitalized upon, until the healthcare industry incorporates ways to identify and extract key information in order to use it for the improvement of patient care. Intelligent and ease of data capture coupled with data mining tools are essential for healthcare providers striving to provide evidence-based, data-driven care while meeting reporting requirements and focusing on clinical quality and process improvement amidst growing regulatory mandates and the need for relevant, actionable information at the point of care.

Leveraging data in new, smarter ways to affect care delivery proactively verses reactively will in turn improve clinical outcomes, patient safety, efficiency, and cost of care. Tools to support the capture, understanding, access, and use of data are evolving quickly through the strategic partnerships of vendors and healthcare organizations. End-user participation is critical to the development and refinement of these tools. Expanding vendor partnerships, maintaining focus on the value of our client partnerships, and continuing to innovate collaboratively is more important than ever before. Designers and users of healthcare information technology must work together to develop, deploy, and maintain innovative healthcare information technology solutions.

As we explore how healthcare organizations can support clinicians and ancillary staff through this transformation in healthcare and with the adoption of the EHR via supportive technology that facilitates the capture, understanding, and use of insightful, actionable data, we should consider the following:

Leverage mobile technology solutions – Provide clinicians with the ability to capture and access insightful information anytime, anywhere, via any device and encouraging both access and capture at the point of care where the greatest value can be derived. Keeping lifesaving data at the fingertips of those who need it to make informed decisions is crucial to improving outcomes, safety, and cost in healthcare. Mobile access to information in real-time can support clinical documentation improvement, CDS, real-time surveillance, reporting, and reimbursement initiatives while facilitating efficiency, collaboration, and improved productivity. Promoting the capture of and access to complex information in real-time supports reliable, complete information and reduces the chance of errors that may arise from attempting to recall all of that information and make decisions at a different point in time. This method of leveraging data also supports engaging patients in the participation of their care and adding value to the patient experience.

Unleash the power of voice – Digital data can be acquired though methods such as voice recognition, transcribed documents, or structured templates within the EHR. Collectively, the structured and narrative components of clinical records provide a comprehensive story of the patient encounter that can be leveraged for CDS, real-time surveillance, reporting, and reimbursement. Making the EHR user-friendly and smart is critical to adoption and for realizing the ultimate value that resides within this technology. Increasingly, EHRs are incorporating tools and functionality that helps to streamline the capture of both structured and narrative data. With a voice-supported EHR, a balance between template-based charting methods and free-text narrative can be made possible to support a complete, reliable account of the patient encounter and ensure the timely entry and access to critical information to support patient care. Arming the healthcare team with tools to document and navigate the clinical record by speaking supports an efficient and effective workflow that promotes accessing information and the input of supporting data at the point of care while actively engaging the patient as a member of the team. Integrating and deploying such tools is a logical step in ensuring safety, reliable information, and fostering collaboration. While documentation is vital to key initiatives and optimal care, enabling the healthcare team to focus on the patient and the care of that patient, which is and should remain our number one priority, instead of the time needed to document that care is the ultimate goal.

Capitalize on the evolution of Natural Language Processing (NLP)/Clinical Language Understanding (CLU) – The opportunities to leverage CLU are emerging quickly to support the transformation occurring within healthcare. CLU tools can bridge the gap between dictated notes and discrete data by allowing clinicians to use their preferred methods and workflow to capture information regarding the patient encounter in narrative form while allowing that data to be extracted into discrete, assessable, accessible data elements to support CDS, surveillance, workflows, reporting, reimbursement, and more. Understanding technology can support the understanding and extraction of key narrative information to populate the EHR while facilitating efficient data capture, enhance abstracting and reporting for quality and performance improvement initiatives and mandates, support real-time surveillance of high-risk patients, intervention opportunities, and early indicators for deteriorating clinical conditions and adverse events to further expand CDS while enhancing clinical documentation improvement efforts to ensure maximum reimbursement.

When exploring strategies to support the capture, understanding, access, and use of data, it is crucial to ensure all members of the healthcare team have a voice at the table. Enabling all members of the team to have the necessary tools to document and retrieve reliable, accurate, complete, and up-to- date information within the clinical record will ensure that patients receive the safest, most effective care possible during the encounter, which will in turn increase clinician and patient satisfaction while improving outcomes, quality, and cost of care. This approach facilitates an innovative culture built around the use of knowledge. This key area of focus will support the goal to make healthcare value-oriented and data-driven.

What tools and strategies is your organization finding effective and efficient to support workflow, the complete and reliable capture of data, and leveraging the data for CDS and surveillance at the point of care? What challenges remain and what would you like to see evolve within and via the tools mentioned above to support such initiatives?

This article was first published on and is used here with permission. You can hear Terri Mitchell discuss this topic on her recent interview on Voice of the Doctor.  Listen to the podcast here.