WakeMed Health & Hospitals: Overcoming EHR Challenges with AI Technology
The Challenge of Documentation Accuracy
WakeMed Health & Hospitals, based in Raleigh, North Carolina, is facing a pressing dilemma with its electronic health record (EHR) system. In healthcare, both financial performance and quality scores hinge significantly on accurate documentation. However, increasing documentation accuracy demands more time from physicians in an EHR that is already a source of frustration and burnout. Research indicates that clinicians may need up to two hours of data entry for every hour of patient contact, and those with inadequate time for documentation are nearly three times more likely to experience symptoms of burnout.
This precarious situation creates a ‘rock and hard place’ scenario for WakeMed. The organization must enhance documentation for financial and quality outcomes, yet pushing physicians harder to document details risks exacerbating their job dissatisfaction and well-being. Dr. David Kirk, Chief Clinical Integration Officer at WakeMed, captures this sentiment perfectly: “Many of our clinicians express frustration, saying, ‘This isn’t what I trained for – I trained to care for patients, not to code charts.’"
Crisis Amidst a Pandemic
The COVID-19 pandemic has further complicated matters, leaving many healthcare providers already fatigued. Dr. Kirk highlights the need for a solution: “We had to find a way to improve charting while alleviating the burden on our clinicians.” This led WakeMed to investigate artificial intelligence (AI) technology as a potential solution.
A Multifaceted Proposal
WakeMed adopted a comprehensive three-pronged strategy that integrated data, personnel, and advanced technology components. The hospital systematically identified that the most significant documentation improvement opportunities existed within the hospitalist team. To address this, WakeMed implemented an AI-powered clinical insights platform from the vendor Regard and provided specialized training for its physicians.
“We offered protected time for a hospitalist leader to facilitate education about the project and highlight specific opportunities related to clinical conditions,” said Dr. Kirk. The Regard application proposes diagnoses and supporting evidence after thoroughly reviewing a patient’s electronic record, which has proven crucial for initial adoption and clinician satisfaction.
Revolutionizing Documentation
The AI technology directly confronts the documentation challenges faced by physicians within the facility. This system integrates seamlessly with the EHR, analyzing charts to extract relevant clinical insights, summarize patient records, and enhance diagnoses with supporting evidence. This automation substantially reduces the time physicians would have otherwise spent compiling data manually.
For instance, when a physician diagnoses a patient with sepsis, the AI application can provide layers of clinical evidence to substantiate that diagnosis. “This not only enhances our documentation but also ensures the patient’s condition is accurately depicted—crucial for proper reimbursement and quality scoring,” emphasized Dr. Kirk.
Focusing on Patient Care, Not Paperwork
Currently, the AI integration is primarily implemented with the hospitalist team, who are responsible for most inpatient documentation. These clinicians still review and finalize the AI-generated information, but the technology significantly reduces the time required to compile and organize critical data, allowing them to concentrate more on clinical decision-making.
WakeMed has plans to expand this technology to other service lines, such as critical care, and ultimately to all physicians and advanced practice providers within the organization.
Impressive Initial Outcomes
Though WakeMed is still early in its journey toward improved documentation accuracy, the results thus far have been compelling. The integration of AI technology has resulted in over $9.3 million in claims that might have otherwise been denied. This not only alleviates lost revenue, reduces administrative burdens, and speeds up payments but also ensures timely care for patients.
Additionally, the system has generated $871,000 in new revenue for Medicare Severity Diagnosis-Related Groups (MS-DRGs), which determine hospital reimbursement for inpatient services. These increased reimbursements occur because the hospital is better demonstrating the treatment of more complex cases.
Enhancing Quality of Care
The improvements extend beyond financial gains. WakeMed has also achieved a 3% increase in the severity of illness identified—supporting clinicians in forming more tailored care plans. This clarity also facilitates smoother transitions and handoffs between healthcare providers, effectively communicating patient complexity.
Moreover, the AI-driven solution has improved the CC/MCC capture rate by 3.6%, positively impacting metrics related to Hospital Compare and CMS star ratings, pivotal elements affecting both public perception and reimbursement.
Tackling Cultural Resistance
Dr. Kirk has identified that one of the biggest hurdles regarding the adoption of AI-powered clinical insights isn’t merely technical—it’s cultural. “Many physicians still view the chart as a narrative tool, and they may resist shifts toward documentation focused on coding and revenue,” he noted.
Communicating the Importance
To encourage adoption, it’s crucial to effectively communicate the importance of documentation improvement not just for revenue but for enhancing risk-adjusted quality scores. “Clinicians are often more excited about quality improvements than just financial metrics,” Dr. Kirk stated.
Involving healthcare professionals early in the adoption process is essential. Demonstrating how AI tools can enhance patient care rather than merely serving the hospital’s interests fosters acceptance.
Building Trust Through Technology
“Accurate documentation serves a dual purpose: it ensures proper reimbursement and guarantees continuity of care, providing a comprehensive view of each patient’s condition,” Dr. Kirk concluded. His goal is to build trust and show the inherent value in integrating AI solutions in a way that supports—not undermines—physician expertise.
The Road Ahead
In summary, WakeMed Health & Hospitals is successfully leveraging AI technology to transform its documentation processes while keeping the focus firmly on patient care. By utilizing innovative solutions that streamline workflow and improve accuracy, they are enhancing both operational performance and clinician well-being. The integration of AI in healthcare is not just about technology—it’s about revitalizing the healthcare workforce and enhancing patient outcomes.
As WakeMed continues to navigate the challenging waters of healthcare documentation, other organizations can learn valuable lessons from its innovative approach to improving quality and efficiency while keeping clinician burnout at bay.
