The accuracy and completeness of clinical documentation are essential ingredients for the achievement of integrated, effective, efficient and safe delivery of care.

LONDON, UK - (HealthTech Wire / News) -  Bespoke research by Ignetica, commissioned by Nuance Communications Ltd, due to be published in May aims to provide healthcare professionals with the first in-depth insight into the impact that the accuracy and completeness of clinical documentation has on the patient experience, as well as doctors’ and nurses’ ability to care and on the overall economics of a Trust.  Entitled ‘The Clinical Documentation Challenge’, it is being conducted by specialist research and management consultancy company, Ignetica and commissioned by speech and imaging technology company Nuance Communications Ltd. The research is being carried out within NHS England Secondary Care Trusts in an effort to establish measures of business value of clinical documentation within the Trusts.

What is the scope of this unique research?

The research – which uses the Business Value of IT (BVIT) methodology to derive an associated economic value to Trusts - is envisioned to be used as a tool to nurture a discussion with department heads about benchmarks and improvements to identify data quality, process improvements and cost savings. With this information soon available for the first time, Trusts will now be better informed and able to develop robust business cases for investments in people, processes and technology to drive improvements in clinical documentation and patient care. 

Not only is the research necessary, according to Booth, it has also been welcomed. “As we’ve got into the interviews, we’ve realised there are high levels of interest in what might seem like a pretty ‘dry’ area of research. We’re really heartened by that fact that in the Trusts we’ve interviewed, the CCIOs, CIOs and clinicians' recognise this area as very important to get right.” He added: “It’s an important element in their day to day work toward improving quality and outcomes in patient care and efficiencies in the delivery of care and services. They’re welcoming a more empirical approach that will provide some data points for establishing baselines for best practice.”

Implications due to the lack of accuracy and completeness of clinical documentation

So far the research has already established that patient delays due to “information gaps” can be considerable and when aggregated contribute to a patient’s increased length of stay; an issue that is very topical within the NHS due to the current bed blocking crisis. It has also found that CCIO perceptions are that the benefit of Electronic Patient Records (EPR) is having electronic information to enable decision support systems, improved safety, reduced communication delays and productivity gains. However, for clinicians this can mean the reverse, which calls into question what is the most appropriate method for entering data into an EPR.

Explaining the rationale behind the research, Booth stated: “In light of the huge investments being made across UK healthcare in technology and processes to support the achievement of a number of government initiatives, it is essential to have a comprehensive mapping and analysis of the flow of clinical information across typical Trust patient care pathways. The research will enable us to identify amongst these pathways those areas which are potentially most sensitive to clinical document accuracy and completeness, and, critically, to quantify the impact of clinical documentation in these areas on patient care, doctor and nurse efficiency and Trust economics. However, despite the accuracy and completeness of clinical documentation being essential ingredients for the achievement of integrated, effective, efficient and safe delivery of care there has not been any research relevant to the UK healthcare environment.”

Although for time and cost reasons the research has been restricted to secondary care pathways, Booth is adamant that the general issues highlighted extend into primary and social care, too. Booth added that the research is already revealing insights of high relevance and value to decision makers and stakeholders within the Trusts who have made - or are about to make - investments in digitising a Trust through EPRs and other clinical documentation.

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Source: HealthTech Wire

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