Workflow: It’s among the most daunting challenges physicians currently face in their day-to-day professional lives whether within electronic health records systems or other software. And that holds particularly true when it comes to coding and documentation.

With the aim of helping hospitals and networks make documentation easier for doctors, 3M Health Information Systems will unveil today its 360 Encompass MD System, an add-on module to the company’s 360 Encompass software, which essentially rolls together computer-assisted coding and clinical documentation tools.

Nicknamed “360 MD,” the new module features prompts for missing documentation and ICD-10 specificity, and a copy-paste risk analysis tool.

Trinity Health in Ann Arbor, MI is among a fistful of providers that have tested a beta version of 360 MD. The network already had the 3M Encompass platform implemented in all 89 of its hospitals, according to Trinity’s Acute Care CMIO Errol Soskolne, MD, and it plans to move 360 MD out of pilot phase “in about a month.”

Thus far the hospital has used 360 MD for the copy-paste functionality. In the past, Trinity encouraged doctors to copy-paste as an onboard to the electronic world but found some early challenges, notably that some physicians were copying records without reading them while others copied too much information and had 10- or 11-page progress reports, Soskolne said.

“A lot of our focus now is how to use copy and paste constructively,” Soskolne continued. As part of its pilot, Trinity makes three “strong recommendations” to doctors: you have to read what you cut-and-paste, only copy relevant information not pages and pages of records, and review every single item when copying a care plan.

“At this point we’re not enforcing them,” Soskolne added. “But we’re scoring discharge summaries based on these criteria, and in order to be re-credentialed your documentation has to be adequate.”  

Primarily because so much can go wrong, copy-and-paste has come under fire. Doctors can miss data including information critical for patient care, they can cut-and-paste too much and, of course, the issue that gets the most attention is the potential for upcoding and intentionally or mistakenly overbilling. They all carry legal obligations.

“Copy-paste is a really helpful tool — if it’s used right,” Soskolne said. “The solution is finding a way to manage it adequately.”

Looking ahead to ICD-10, Trinity is planning to use 360 MD to supplant the classroom training it previously conducted because Soskolne wonders how much training physicians even remember at this point. The 3M tool essentially walks clinicians through the list of what they must do when documenting in ICD-10 and can prompt them of any data left out, such as laterality. The idea being that, in time, doctors will learn not only how to use ICD-10 but also the codes they use most frequently.

Trinity is one of five pilot sites to have worked with 360 MD and now that it’s ready for prime time, 3M said it is working to make it widely available in the third quarter of this year.