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Electronic Documentation in Hospice
Electronic documentation is a tool that helps health care professionals document the care they provide in a succinct and uniform way. Several initiatives have been implemented to encourage the use of electronic documentation in hospice. This chapter discusses general information about electronic charting and documentation tips specific to hospice.
After reading this chapter, you will be able to:
■ Discuss the use of electronic charting in hospice
■ Identify incentives for the use of electronic health records
■ Describe proper hospice documentation
Fast Facts in a Nutshell
“Electronic medical records (EMRs) are increasingly viewed as essential tools for quality assurance and improvement in many care settings” (Zheng, Rokoske, Kirk, Lyda-McDonald, & Bernard, 2014, p. 582).
ELECTRONIC DOCUMENTATION
Most quality reporting is done through medical chart review. Use of electronic records allows easier access to vital information and more uniform documentation. Further, health care providers are more likely to document components of quality if prompted to do so within the electronic health record. Thus, use of electronic records is one way to improve compliance and monitor quality (Cagle et al., 2012). Electronic health records also allow remote access to charts, and improve overall patient care (King, Patel, Jamoom, & Furukawa, 2013). Advantages of electronic charting include:
■ Improved access to interdisciplinary notes
■ Automatic prompting to document key items
■ Uniform documentation by all providers
■ Easier access to needed information
Barriers to the use of electronic charting include:
■ Implementation costs
■ Staff training
■ Limited availability of software that is hospice-appropriate
■ Lack of system compatibility (Cagle et al., 2012)
ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM
The American Recovery and Reinvestment Act of 2009 established incentives for the incorporation of electronic health records. The goal of expanding the adoption of health information technology, such as electronic health records, is to promote continuous quality improvement and information exchange at the point of care. In order to participate in the incentive program, an organization must demonstrate meaningful use of health information technology (Centers for Medicare & Medicaid Services, 2016).
“Meaningful use” means that hospice organizations will use electronic health records to (HealthIT.gov, 2015a):
■ Improve the quality of patient care
■ Increase collaboration with patients and families
■ Promote care coordination
■ Improve the privacy and security of health information
The ultimate goals of the incentive program are (HealthIT.gov, 2015a):
■ Improving clinical outcomes
■ Increasing efficiency
■ Empowering patients through easier access to their own medical records
Following are the three stages of the incentive program (Centers for Medicare & Medicaid Services, 2016; HealthIT.gov, 2015a):
■ Stage 1 (2011–2012): Data collection and sharing
■ Stage 2 (2014): Advanced clinical processes
■ Stage 3 (2016): Improved outcomes
To attain meaningful use and receive the incentive payments, hospice organizations must demonstrate that use of the electronic health record has enabled streamlined processes; enhanced communication within the hospice team, with other providers, as well as patients and families; improved patient safety; and improved patient and family access to self-management tools (HealthIT.gov, 2015b). Meaningful use also enables standardized documentation of assessments, interventions, and outcomes, which promotes uniform patient care.
Fast Facts in a Nutshell
