Clinical documentation improvement has been a major focus of many health systems' value-based care initiatives. But getting to more efficient and more accurate charting, especially for providers using older electronic health record systems, is a tall task with no dependable template for success.

But in AHIMA's Perspectives in Health Information Management, four experts from the Mayo Clinic College of Medicine showed how their department – the college's Department of Physical Medicine and Rehabilitation – used Lean processes for a redesign of an inefficient, first-generation EHR documentation system.

The project was a success, at least with respect to a boost in productivity and staff morale.

[Also: How NYU Langone tweaked its Epic EHR for value-based care, saving millions]

"The implementation of Lean methodology applied to EHR documentation template inefficiencies proved to be an effective way of reducing time spent in the EHR by therapists, improving therapist productivity, and increasing satisfaction of internal and external stakeholders," said the Mayo Clinic experts.

Specifically, by bringing Lean methodology to bear on documentation template inefficiencies, Mayo staff were able to reduce time spent in the EHR by therapists, improve therapist productivity and increase the satisfaction of internal and external stakeholders.

Using Lean processes enabled reductions in time spent using the EHR from 2.8 hours per day to 1.9 hours per day per therapist, the researchers said. It helped increase time spent on direct patient care from 53 percent to 71 percent. And it led to increased satisfaction levels for both internal stakeholders (from 17 percent to 97.4 percent) and external stakeholders (43 percent to 80.3 percent, respectively).

"Lean methodologies, which have been used for several decades in the industrial sector, are increasingly being applied to healthcare to drive quality improvement in order to reduce or eliminate errors, delays, and redundancy," wrote the Mayo Clinic staffers in the AHIMA article.

Having identified ongoing EHR limitations in a documentation system designed for inpatient and outpatient physical therapists and occupational therapists, leadership of the Department of Physical Medicine and Rehabilitation through a Lean Six Sigma approach could help – specifically the Define, Measure, Analyze, Improve and Control framework.

"The central problem identified by rehabilitation therapists when utilizing the original EHR was reliance on a poorly designed documentation template characterized by an excessive amount and redundancy of information, which resulted in a protracted, unclear text rendition," they explained.

"Rehabilitation therapists, physicians and other providers often described difficulty finding important material in the patient evaluation or treatment notes. Despite the fact that the system was custom-built for the department, neither the end users (rehabilitation therapists) nor the note readers (physicians and other providers) had been included in the initial planning phases, nor had they been given an opportunity to provide feedback on the template design or content."

The Mayo team identified three big aims for the Lean project: reduce the average amount of time therapists interact with the EHR by 35 percent; increase staff productivity in units of services charged per patient by 10 percent; and improve stakeholders’ satisfaction to 80 percent in the stakeholder satisfaction survey.

Use of the DMAIC framework led to improvements in those and other areas, but the researchers made sure to point out that, those gains notwithstanding, Lean may not be a cure-all for other challenges related to EHR documentation.

"Similar efficiencies may be less evident in the areas of documentation creation, readability, and usability of information found in provider evaluations and treatment notes, and reports of increased documentation time have led to reduced direct patient care time," they said.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com