The role of clinical information systems in improving physician productivity: Challenges facing the adoption of an electronic charge capture system

Regulatory compliance requirements of maintaining complete patient records and clinical documentation increase the administrative tasks of the housestaff and hospitals. Clinical information systems have been comprehensively adopted to assess the quality of care and outcomes, to improve the performance of health care providers, and to support health care information management. Our billing operation has experienced the need of an extended processing time to cope with the charge capture tasks related to physician reimbursement. We developed a semi-automated charge capture system assisted with information technology to improve the billing interface and promote physician productivity. This pilot system was adopted to test our hypothesis that information technology could improve the billing workflow. Physicians found that electronic juxtaposition of the pilot system with the electronic medical record (EMR) helpful in patient data verification from the progress note. The pilot system was successfully designed to assist physicians to improve productivity. Clearer changes in physician behavior and organizational management are needed to reduce administrative cost and prevent further errors. Although overall technical improvement may provide access to desired information, major barriers on data entry still hamper the efficient implementation and adoption of clinical information systems.