Clinical Documentation Strategies 2023
Examining Which Options Best Fit Your Needs

Market Overview: Outcomes and Value Top of Mind in Provider Decisions

Over the last three years, healthcare organizations have seen increased employee attrition, heightened levels of physician burnout and dissatisfaction, and increased costs that have squeezed already tight profit margins. As a result, outcomes and value are top of mind for provider organizations as they consider their documentation strategies, even taking precedence over technology consolidation, which is a focus for organizations in many other areas. The outcomes that are most frequently commented on include improved dictation accuracy, increased capture of billable issues, correctly identified and coded encounters, reduced time spent preparing and reviewing documentation, and improved documentation closure times to decrease outstanding A/R days.

Ambient Speech Recognition: Technology Rapidly Growing and Showing Initial Promise

Market Insights: While there are a few vendors that either employ or are working on ambient speech technology, this is still a newer market that is not yet fully measured by KLAS. However, it is a rapidly developing area, and KLAS is looking to measure these solutions more fully in the future.

Front-End Speech Recognition: Becoming the Go-Forward Platform for Documentation

Market Insights: Provider organizations report that the overall market is moving toward speech recognition as the go-to documentation platform. Respondents feel that speech recognition has improved over the last couple of years in its accuracy and ability to detect accents, at least to the point that it is on par with the accuracy seen in transcription. Another big selling point is variety in platform type, as providers can now often use their mobile phones to capture dictation and review and approve notes. The biggest hurdle with front-end speech recognition may be the cost; respondents feel there is nickel-and-diming on top of what is already considered an expensive system.

CAPD: Organizations See Benefits, but Physician Buy-In Remains Low

Market Insights: Almost all respondents mention the benefits of CAPD; the real-time nature of CAPD enables more efficient code capture and therefore improved revenue and reduced documentation time. Still, adoption among physicians is proving to be a challenge for a few reasons. Some Nuance clients, for example, feel the CAPD system doesn’t fit within a physician’s typical workflow, and 3M customers often say that recommendations fire too frequently, interrupting the patient encounter, so those are ignored or turned off. Some provider organizations using CAPD solutions cite inaccurate or erroneously fired recommendations.

CDI: Technology Drives Results, but Development Has Been Slow

Market Insights: Customers note that CDI software often provides a solid ROI through increased billing capture, more efficient workflows, and improved prioritization and guidance. There is currently wide adoption of CDI in the inpatient space, and there is significant growth of CDI in outpatient care. Even so, provider organizations feel that development of CDI software overall has stagnated. An exception to that may be Iodine Software, who respondents see as a highly innovative company. Customers of 3M, Dolbey, and Optum feel they aren’t seeing any appreciable or timely improvements. They note that upgrades and incremental changes are being implemented but that the core software components have not been updated. Provider organizations don’t anticipate many major changes occurring in the future.

Transcription Services: Adoption Decreasing, but Still a Valuable Part of Provider Workflow

Market Insights: With speech recognition on the rise, provider organizations are starting to move away from using transcription services and in-person scribes. Even so, respondents feel that transcription will continue to play a limited but important role in documentation. Transcriptionists and scribes have been especially useful as an aid for physicians who are hesitant to adopt speech recognition technology and as a backfill for organizations with large documentation backlogs.

In general, customers are satisfied with their transcription firm’s ability to meet or even exceed contractual obligations with turnaround times while ensuring accuracy and thoroughness. When customers do find errors or inconsistencies, they feel their firms are responsive to correction requests.

The transcription market has recently seen a lot of change, as AQuity Solutions has spun off from MModal after being acquired by 3M, and as DeliverHealth has acquired Nuance’s transcription services arm. As a result of these changes, respondents feel that their relationships with their firms have suffered slightly. Client satisfaction with executive involvement, proactive service, and communication have all recently declined somewhat.

Virtual Scribes: Still Having Highly Positive Impact, though Replacements Cause Inconsistencies

Market Insights: 94% of respondents feel that their virtual scribe has a positive or highly positive impact on their documentation time, and most mention that their documentation is completed by the end of the day. Provider organizations are most likely to recommend using a virtual scribe as a bridge to help achieve same-day closures when physicians are having difficulty closing their notes in a timely manner.

The main reported issue with virtual scribes is the inconsistent quality of scribes. The best scribe-physician relationships are developed through consistency and longevity. With replacement scribes, respondents note that it is difficult to maintain the same level of high-quality output and that the process to bring up a new scribe is long and difficult.

About This Report

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluations for healthcare software and services. The software evaluation is composed of 16 numeric ratings questions and 4 yes/no questions. The services evaluation is composed of 9 numeric ratings questions and 3 yes/no questions. Both types of evaluations weigh all questions equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars for software (culture, loyalty, operations, product, relationship, and value) and five customer experience pillars for services (loyalty, operations, relationship, services, and value).

Sample Sizes

Unless otherwise noted, sample sizes displayed throughout this report (e.g., n=16) represent the total number of unique customer organizations interviewed for a given vendor or solution. However, it should be noted that to allow for the representation of differing perspectives within any one customer organization, samples may include surveys from different individuals at the same organization. The table below shows the total number of unique organizations interviewed for each vendor/services firm or solution as well as the total number of individual respondents.

Some respondents choose not to answer particular questions, meaning the sample size for any given vendor/firm or solution can change from question to question. When the number of unique organization responses for a particular question is less than 15, the score for that question is marked with an asterisk (*) or otherwise designated as “limited data.” If the sample size is less than 6, no score is shown. Note that when a vendor/firm has a low number of reporting sites, the possibility exists for KLAS scores to change significantly as new surveys are collected.