3 Challenges of Digital Patient Documentation and How to Solve Them

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Top Story: 3 Challenges of Digital Patient Documentation and How to Solve Them

When it comes to patient documentation, physicians bear the weight of significant paperwork and routine tasks. According to the 2023 Medscape Physician Compensation Report, physicians spend an average of 15.5 hours per week on paperwork and administration.

Manual processes strain staff and hinder patient interaction and timely care delivery. Studies have shown that 40-80% of the medical information doctors tell patients during office visits is forgotten immediately, and nearly half of the information retained is incorrect.

The latest solution, digital clinical patient documentation, can facilitate inter-provider communication, allow evidence-based healthcare systems to automate decisions, provide evidence for legal records, and create patient registry functions so public health agencies can manage and research large patient populations more efficiently.

Some of the most notable benefits associated with digital documentation include reducing care team burden, improving clinical documentation quality at the point of care, avoiding common deficiencies and poor penmanship, and decreasing costs at the healthcare system level.

But while many organizations are already searching for tools, others still fear that this technology will drive a wedge between patients and physicians by compromising patient safety or leading to AI bias. Other organizations are stumbling over issues such as proper workflow integration and ensuring data integrity.

The good news is there are simple ways to prevent this.

Let’s take a look at the challenges and solutions for integrating digital patient documentation technologies into your practice and ensuring smoother patient visits.

Challenge 1: Data integration/ integrity

One of the most prominent challenges organizations face with digital patient documentation is managing data integration and maintaining data integrity. 

Prior to implementation, organizations must ensure that potential solutions are compatible with their EHR system and will not compromise data or require manual workflows to send patient data notes to the correct electronic health record (EHR).

Patient visit records should then be successfully integrated into existing EHR systems by automatically transmitting patient visit summaries after patient visits. Automated systems prevent data loss, mishaps, or errors. In turn, this process can improve care and ensure the accuracy and consistency of information throughout the patient care cycle. 

During this process, data integrity is critical. Data integrity means that all the information your healthcare organization interacts with and shares is accurate, trustworthy, and consistent.

Keeping patient information integrity high requires software that utilizes AI machine learning tools trained with specific medical data sets. These trainings focus on systematically summarizing visits, helping with differential diagnoses and can filter out unneeded casual conversations or information.

Therefore, it is important to check with your tech provider to understand what machine learning (ML) technology they use to fit your needs and keep open communication about updates, technology innovations, and AI learning sets with the provider to ensure constant evolvement.

Challenge 2: Workflow integration

As important as data integration and integrity are when introducing new digital technologies for patient documentation, adapting team workflows is crucial to truly benefit from patient documentation.

First, physicians must match AI-generated summaries with the words spoken during the patient visit to ensure verifiability and foster trust between patient and physician. By focusing on keywords such as diagnosis, symptoms, prescribed medications, and next steps during the summary, this process should be cut by a fraction of the time compared to manual transcriptions.

Another workflow integration relates to aftercare. Immediately after a visit, the patient can receive the AI-generated summary of their medical care via a secure access portal. And by sending related health notifications, such as reminders to take medication or schedule follow-up appointments, you can ensure that patients adhere to health advice and, thereby, improve overall health outcomes. This process helps patients become more involved in their care and provides better follow-up care cycles.

Challenge 3: Data security and HIPAA compliance

One of the biggest issues with clinical documentation is patient data security. Health information databases contain sensitive patient information, including patient names and addresses, tests, diagnoses, treatment, and medical history. Between January 1, 2023, and October 31, 2023, over 82.6 million healthcare records were exposed or impermissibly disclosed, compared to 45 million records in 2021 and 51.9 million records in 2023.

All patient data should always be secured and protected from tampering and fraudulent use by third parties. By working with the provider and viewing their storing processes, you can verify compliance with HIPAA and the highest security standards when integrating digital patient documentation.

Ideally, the applications used for patient documentation will not store any records or data. This means every new patient visit should start with a clean slate. Secure software records the conversation, summarizes the information, sends it to the doctor for approval, and then transfers it to the electronic patient record, where it is securely stored and immediately deletes all data within the application.

Digital patient documentation is a necessary solution for overworked staff, but only its accurate and secure implementation guarantees good results in the long term. That’s why finding a suitable provider who can respond to your questions is so important.

Did you know Steer Health is offering a secure solution for patient documentation? Learn more below.

Document patient visits with less effort and more security

Steer Health recently launched SteerNotes, a groundbreaking solution that leverages AI to streamline documentation and communication. Press record and start prioritizing what’s important: patient care, not paperwork.

By automating repetitive tasks and personalizing patient instructions, SteerNotes empowers clinicians, improves care delivery, and enhances patient engagement.

Our innovative technology features:

  • Automated Note Generation: SteerNotes uses AI to analyze patient data and generate complete, accurate notes in real time, eliminating the need for manual transcription and repetitive typing.
  • Personalized Patient Instructions: Clear and concise instructions are tailored to individual patient needs and learning styles, ensuring comprehension and addressing potential concerns early on.
  • Streamlined Workflows: Intuitive interface integrates seamlessly with existing EHR systems, minimizing disruption and maximizing efficiency.

Digital patient documentation is a new age and can save up to 9 hours per week in time savings, improve the patient experience, and boost data integrity. However, during the implementation phase, it is advisable to collaborate with a reliable partner and opt for a fully compliant and secure platform provider such as Steer Health.

Ready to transform your practice? Experience the future of clinical documentation with our 60-day, no-commitment free trial. Discover how SteerNotes can revolutionize your practice today!

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