Whether it's the migration to value-based purchasing and pay for performance, increased scrutiny under the federal recovery audit contractor program or simply achieving internal benchmarks, pressure is mounting on hospitals to improve clinical documentation.

Sean Benson, vice president of consulting for ProVation Medical, says changes in documentation are most effective when they begin with "areas where you can actually see a quick win," such as with nurses, who are usually quicker than physicians to embrace technology.

He recommends setting aside staff specifically to manage clinical documentation. If the software is not easy to use and doesn't make their job easier, physicians will not use it. Just as important, he adds, hospitals need to figure out ways to use the data to improve patient care.

According to data from the HIMSS Analytics, by the third quarter of 2010, 49.7 percent of U.S. hospitals had systems that could combine patient data culled from a variety of sources. Only 10.3 percent had systems that actually assisted in clinical decisions.

The newest piece of clinical documentation at Geisinger Health System in Danville, Pa., is natural language processing that can read a clinician's free text and pull out keywords. But Thomas Graf, Geisinger's chairman of community practice, attributes the health system's improvement on some indicators proposed under Medicare's value-based purchasing program in part to getting patients more involved in their own clinical documentation. Patients in the Geisinger program can not only read their electronic medical record, but also give feedback or add details to their progress reports.

Patients also can click on a series of factors based on the Framingham Heart Study and see in real time the effect such behavioral changes as smoking cessation or increase in exercise could have on their health, based on their EMR.