Enhancing Medical Record Documentation at the Department of Veterans Affairs

The DSS EMT solution streamlines the process of completing and tracking documentation, ensuring timely completion, regulatory compliance, and improved patient care communication. 

For the Department of Veterans Affairs (VA), timely medical record documentation has been an ongoing challenge since the use of paper records. In the current electronic era, while the medium has changed, core challenges persist. 

For example, clinicians are required to complete necessary documentation to meet regulatory requirements around Joint Commission accreditation standards, timely billing for better revenue cycle management, legal matters, and operational needs for seamless patient care communication. 

In addition, the VA currently uses manual VistA reports, and disparate processes and tools across different facilities, making it difficult to manage documentation. As a result, the manual tracking and follow-up by the Health Information Management Service (HIMS) is time-consuming and inefficient.  

Historically, the VA HIMS department has held the task of managing documentation completion and constant follow up with doctors to ensure they author and sign the different document types within the regulatory required timeframes.  

Introducing the Encounter Management Tool (EMT) 

Developed by DSS, the new Encounter Management Tool (EMT) is designed to optimize the management of medical record documentation within the Department of Veterans Affairs (VA). This solution streamlines the process of completing and tracking documentation, ensuring timely completion, regulatory compliance, and improved communication related to patient care.  

EMT also addresses issues of clinicians struggling to complete documentation on time and allows users to act directly within the tool. This web-based application offers:  

• Actionable Worklists: EMT allows users to directly act on items from the dashboard or worklist. This feature aims to reduce double data entry and the need to switch between multiple applications. Users can not only view what documents they need to complete but also act on them from the dashboard view or worklist. 

• Streamlined Access: The tool streamlines the view of information, allowing users to manage encounters and unsigned/cosigned TIU (Text Integration Utility) notes within a single platform.  

• Real-Time Updates: Signatures completed in EMT directly update VistA/CPRS in real-time. 

• TIU Note Management: The tool includes functions for administrative users to manage TIU notes, including reassigning, editing co-signers, amendments, and changing note titles. 

• Customized Reporting: The EMT solution provides customized data views and reporting capabilities to track documentation compliance. 

The new EMT solution has the potential to transform both administrative and care outcomes for the VA in the following ways:  

• Improving Clinical Workflow: By providing a streamlined and actionable platform for documentation, the tool seeks to optimize clinical workflows and improve overall efficiency. 

• Enhancing Patient Care: By ensuring that documentation is complete and timely, the tool will support improved communication, better informed decision-making, and ultimately, better patient care.  

• Reducing Administrative Burden: The EMT solution reduces the manual work of the HIMS department by providing automated solutions for managing documentation. EMT also helps to counter provider burnout and enhances communications between administrators and clinicians.   

• Saving Time and Eliminating Data Duplication: By consolidating documentation functions into a single application, the EMT reduces time spent switching between programs and eliminates duplicated data entry.  

• Supporting Regulatory Compliance: By ensuring documentation is completed in a timely manner, the EMT supports VA's regulatory compliance efforts. 

The overall goal of any health IT solution should be to make life easier for clinicians and administrators. Our new EMT offering does precisely this by allowing the VA to streamline critical administrative tasks though the automation of manual processes and consolidating them within a single application. 

As a result, the VA can better meet Joint Commission accreditation standards, enhancing billing for better revenue cycle management, be prepared to better address legal matters, and make patient care communication seamless.  

Learn more about the Encounter Management Tool. Contact us today to schedule a demo of the new DSS EMT solution.