Clinical Documentation Trends – Must READ
I know you will want to read this over carefully. There are some VERY interesting points made in this study by the Health Business Group on healthcare documentation trends for the next several years. Please take time and read, as it is well worth it … (my medical transcription and healthcare documentation friends)!
Clinical_Documentation_Trends_2013_2016
“CLINICAL DOCUMENTATION TODAY
• Medical transcription is the most common form of documentation in the acute care market and is also utilized, though to a lesser extent, in the ambulatory space.
• About half of medical transcription is performed by provider organizations using their own staff; half is outsourced to Medical Transcription Service Organizations (MTSOs).
• Acute care providers frequently use both in-house and outsourced resources; ambulatory practices tend to use one or the other but not both.
• Most provider organizations type their transcription directly from audio files.
• A substantial portion of documentation is done using the electronic health record (EHR), especially in the ambulatory market.
• Despite increasing EHR penetration, health care providers express some uncertainty about the ability of EHRs to meet clinical documentation needs and to tell the complete patient story.
• A significant share of clinical documentation is still handwritten.
CLINICAL DOCUMENTATION IN 2016
• The clinical documentation market will undergo substantial change between 2013 and 2016.
• Documentation volume will continue to grow at approximately 2 to 3 percent per year.
• The use of EHRs for documentation will increase, especially in ambulatory settings.
• The use of front-end speech recognition to enter data into EHRs will grow faster than the use of keyboard and mouse.
• Integrated delivery networks (IDNs) will increasingly determine the method of clinical documentation for affiliated practices.
• Documentation on paper will vanish almost completely.
• Transcription will remain an important documentation method, but more of the market will be outsourced.
• There will be increasing use of back-end technology among those who continue to perform transcription in-house.
• New technologies such as Clinical Language Understanding (CLU) will enter the mainstream.
• The introduction of ICD-10 may increase the need for high-quality clinical documentation and Computer-Assisted Coding.”
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