Clinical documentation software sometimes gets a bad rap from those who use it. Doctors and surgeons in particular seem to resist using it. But when used properly clinical documentation software can help a clinic’s efficiency and effectiveness, and help practices make large strides in improving all aspects of their business.
Here are four ways that you can make your clinical documentation software work for your practice.
Train and Then Train Some More
Training boosts familiarity, and familiarity boosts efficiency. But are you training the right people? Many practices will pay for doctors to get training, but medical assistants should also be trained in using clinical documentation software. When assistants are the ones using the system, that frees up doctors to do their jobs -- visiting with, diagnosing and treating patients.
Also look for ways for people to keep their skills fresh. Some vendors provide training after the initial setup as a way to ensure that people aren’t falling into bad habits as they use the clinical documentation software. Work with a partner that can provide the knowledge base your employees need.
One of the obvious benefits of clinical documentation software is that you can increase the level of detail of your medical records. Detailed health records can make it more likely that you will find or prevent medical errors in patient care.
In addition, having detailed medical records can help protect your practitioners in case of a lawsuit. The more details you record in your clinical documentation software, the clearer it is that you are providing the best level of care to your patients.
Prepare for ICD-10
Practices that work with updated clinical documentation software can help ensure they’re ready for the ICD-10 conversion that starts in October 2014. While you have a year to prepare, clinics are going to have to do a lot of work to get ready, and the time to do so is now.
Your EMR vendor should have a plan in place for conversion, and using the latest version of your clinical documentation software will help you learn the new, more complex codes that are coming.
Use it to Manage HIPAA Risk
As changes in technology make electronic health records easier to manage, clinics and practices will still need to keep in mind that they have to stay HIPAA compliant.
You should start with your clinical documentation software and go from there. For example, Dragon Medical software is compliant with HIPAA regulations and any data used is encrypted. But if that data is put in an email and sent to another practice, is that compliant? Probably not. So, start with your encrypted or secure information and then ensure that the process you use to share that information is compliant with the rules.
Using your clinical documentation software to run a more efficient and effective practice takes a little work but can be worth it in the long run. How do you make your clinical documentation software work for your practice?
Logan Solutions uses a combination of clinical practice expertise and technological skill to help physician practices throughout the U.S. implement, customize and improve their ERM and Dragon Medical software systems. Contact us to find out how our clinical-practice expertise can help your practice with its clinical documentation software needs.