Readers Write: Tell Me More: Documentation Support in Telemedicine

Tell Me More: Documentation Support in Telemedicine
By Patty Maynard

Patty Maynard is senior vice president of business development with Health Navigator of La Grange, IL.

A successful telemedicine platform provides value beyond the latest technology or reduced healthcare costs. The most effective platforms focus on workflow, from resource allocation to staff education. In fact, a recent REACH Health survey showed telemedicine can improve outcomes, access to care, and efficiency.

Clinical documentation support (CDS) facilitates reaching these goals. From the chief complaint to the pre-visit, “tell us more” step, CDS can improve workflow. It captures shareable data for medical call centers, telemedicine providers, hospitals, and primary care providers. This data can simplify the pre-visit process, saving time and money. In addition, it provides patients with a familiar and comforting medical interaction, but in a digital format. CDS is part of the back-end content and workflow that make the digital health experience run smoothly.

The more information a healthcare professional has, the easier it is to make decisions. In telemedicine encounters, an easy-to-navigate questionnaire about the chief complaint or symptom can help move the process along.

Imagine knowing a patient’s chief complaint, symptoms, and demographic information before they reach the clinic. This may sound too good to be true, but modern platforms can provide a patient-facing checklist or Rapid Medical History that prompts patients to provide information. Clinicians can review a patient’s Rapid Medical History or use the CDS tool to record patient responses.

For example, a patient using a telehealth application may respond to two of five questions in a pre-visit checklist or Rapid Medical History. In a follow-up call, the clinician reviews the responses and asks any unanswered questions. The clinician then collects relevant information from a standardized CDS checklist and gives care advice.

CDS checklists also help providers ensure staff follow safe, consistent processes with patients. Checklists are especially important in crisis or high-stress situations when staff may forget details. In the long run, checklists help:

• Ensure consistent workflows
• Improve communication
• Reduce provider risk, and
• Save time.

For every chief complaint, there is related information telemedicine providers need to know. The ideal telemedicine platform should have access to content that automatically links a chief complaint to a Rapid Medical History template. A platform that connects chief complaints to a standardized list of questions can save time and improve efficiency. These custom templates can also improve accuracy of care advice.

The traditional, pre-visit process can take a significant amount of time, time that could be spent elsewhere. Incorporating CDS reduces time spent gathering patient background information and allows staff to get to the root of the problem quickly. This leads to faster, more accurate diagnoses and care recommendations. It also creates an alternative to ER or urgent care visits for low-urgency conditions, which make up a large part of telemedicine encounters. CDS can also be used to augment EHRs with data that improve patient tracking.

A standardized clinical documentation support process can transform the telemedicine experience, creating a faster diagnostic process and reducing unnecessary visits. CDS can improve patient outcomes, safety, and satisfaction by delivering a consistent experience for patients and staff. This can help patients feel empowered and gives them tools to make appropriate healthcare decisions. In short, CDS is a building block of a better telemedicine experience with more valuable data.

Moving forward, the healthcare industry will see more of this data processed through artificial intelligence (AI) like natural language processing (NLP). NLP directly relates to CDS because this “narrow AI” produces the standardized, follow-up templates for each chief complaint. These two technologies can improve all areas of telemedicine.

Some of the major areas of opportunity for telemedicine lie in services like tele-ICU, tele-psychology, and triage. CDS allows these services to deliver a richer, data-driven experience. These areas are only expected to grow, and CDS helps telemedicine providers meet patient and provider needs.

As telemedicine falls under new legislation and continues to evolve as a covered benefit, expect to see new guidance on standardization and use. CDS provides data that makes telemedicine visits valuable, fitting into value-based payment models. Telemedicine providers can expect to see increasing demand for these convenient services as employers and health systems work to provide cost-effective, accessible care.