The clinical documentation market in the USA will undergo substantial change in the next two to three years. Some of these will actually be attempts to catch up to markets elsewhere in the world where clinical documentation is actually more advanced than that which is in use in North America.
Documentation Volume is Expected to Grow
In the USA, documentation volume will continue to grow at approximately 2 to 3 percent per year as a result of:
- mandates to explain billings
- efforts to demonstrate quality
- risk mitigation that attempts to prove safety and efficacy
- attempts to proactively defend evidence-based clinical approaches, and
- the need to coordinate globally integrated care among health caregivers and clinical providers
The increase of EHR Adoption
The use of electronic health records (EHRs) for documentation will increase, especially in ambulatory settings in North America. Meanwhile, in other countries such as France, Korea, Malaysia and elsewhere, medical records are already digitized and stored on smart cards, magnetic strips, and other reader devices. These devices integrated medical records, pharmacy data, and insurance plan coverage details and often cost less than $1 USD per person to issue and maintain. They are secure and rarely do we hear of data breaches to the likes of those reported in the USA.
Front-end speech recognition technologies
The use of front-end speech recognition to enter data into EHRs will grow faster than the use of keyboard and mouse. These smart technologies continue to proliferate and are widely in use in other countries throughout the world.
Standardized documentation formats
Integrated delivery networks (IDNs) will increasingly determine the method of clinical documentation for affiliated practices. If they don’t also determine the style and completeness of data, simply standardizing the technology will be insufficient to clinically integrate and align the group’s efforts towards clinical efficacy and continuity of care.
Paper Documentation
Documentation on paper will vanish almost completely. Not only is it socially responsible to eliminate paper records, but
Transcription will remain an important documentation method, but more of the market will be outsourced, but not necessarily to India, Ireland, Philippines, and other countries. The reasons for this are several, starting with HIPAA and HITECH regulations and liability for business associate errors or breaches. The reason these tasks were outsourced previously was because of the human resource cost to have it done in the USA. Now, technology brings these tasks in cheaper and at equal or adequate quality at a cost less than outsourcing it to other nations’ labor forces, but when combined with the regulatory compliance risks, there’s little left to argue.
Artificial Intelligence
New technologies such as Clinical Language Understanding (CLU) will enter the mainstream and Natural Language Processing (NLP) and Machine Learning (ML) together with artificial intelligence in Predictive Modeling such as those in use by Apixio and its competitors will gain larger market shares and faster adoption cycles. These technologies will also spur products that address HCC (Hierarchical Condition Categories) models to adjust capitation payments to private health care plans for the health expenditure risk of their enrollees, and to more accurately enter clinical documentation and better claims reporting and predictive modeling integrity through computer-assisted coding programs.
Lately, we’ve been invited to propose ways to help foreign providers prepare for contracts with US health insurers and employers. First assumptions were that these services were not yet available and would need to be developed by the foreign providers or provided by our experts. In reality, many of the providers simply needed to review the specifications and regulatory requirements. Our consultants then created a crosswalk of requirements and the job was much less complicated than originally anticipated. Will developing nations and health systems outside the US leapfrog beyond the USA and its ego?
