Electronic Health Records

Clinical Documentation

Leveraging Health IT for Clinical Documentation Improvement

April 20, 2016 - Well before the implementation deadline for ICD-10 last October, clinical documentation improvement was a well-established aim of healthcare organizations and providers seeking gains in both clinical efficiency and data integrity. Now with the federal government looking to implement value-based care initiatives tying reimbursement to quality, health systems have even more reason to impro...


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How Providers Use Clinical Documentation Improvement Tools

by Kate Monica

Clinical documentation improvement (CDI) tools can help healthcare organizations accurately represent information about patient health events, clinical status, and office visits in EHRs as coded data. This coded data is used for quality...

Cerner EHR Implementation Goes Live at NE Medical Center

by Kate Monica

Regional West Health Services — the parent company of multi-specialty medical group Regional West Medical Center — went live with a new Cerner EHR implementation over the weekend to streamline health data access and care...

Epic EHR Now Includes Nuance Voice-Enabled Clinical Workflows

by Kate Monica

Providers using Epic EHR will now have access to voice-enabled clinical workflows powered by Nuance virtual assistant technology for faster, more efficient data access. The voice-enabled clinical workflows are now commercially available...

Researchers Doubt Clinical Efficiency, Effectiveness of PDMP Use

by Kate Monica

A team of researchers at Dartmouth-Hitchcock Medical Center determined prescription drug monitoring program (PDMP) use negatively affects clinical efficiency without offering much benefit as a tool for reducing opioid prescribing for...

Cerner to Directly Oversee MCHS EHR Implementation, IT Department

by Kate Monica

Texas-based Medical Center Health System (MCHS) will move forward with an agreement to allow Cerner to take over its IT department and oversee its EHR implementation, according to Odessa American. The Ector County Hospital District board...

EHR System, Physician Burnout Contributed to Problems at ME Hospital

by Kate Monica

Executives at Central Maine Healthcare have been struggling to reduce high rates of physician burnout with 80 of the health system’s 300 employees leaving in the past fiscal year partly because of dissatisfaction with its EHR...

3 Ways to Improve Patient Safety, Diagnoses with Health IT Use

by Kate Monica

Improving communication between providers, diagnostic testing and medication tracking, and documentation through health IT use can help to reduce delayed, missed, and incorrect diagnoses. This set of safe health IT use recommendations was...

5 Ways to Prevent Physician Burnout in the Age of the EHR System

by Kate Monica

Rates of EHR adoption and physician burnout have both steadily risen nationwide in recent years — and research shows that’s no coincidence. Healthcare CEOs in 2017 identified EHR technology as a key contributing factor to the...

CHIME Commends CMS QPP Proposed Rule, AMGA Voices Criticism

by Kate Monica

Stakeholders have expressed conflicting opinions about the new CMS 2019 Quality Payment Program (QPP) proposed rule, which was released July 12 along with proposed rules about the 2019 Physician Fee Schedule.  The rule includes...

CMS Proposes Quality Payment Program Changes, Administrative Relief

by Kate Monica

CMS has proposed key changes to the Quality Payment Program (QPP) intended to reduce administrative burden, shift the focus from process-based measures to outcomes-based measures, and promote EHR interoperability. The 2019 QPP proposed...

Voice Recognition Accuracy Lacking in EHR Clinical Documentation

by Kate Monica

EHR clinical documentation generated through voice recognition software may be error-prone, according to a recent JAMA study. In the study, Zhou, MD, et al. aimed to identify and analyze errors at each stage of the voice...

Collaboration Critical for Improving CDI Across Healthcare

by Elizabeth Snell

Clinical documentation improvement (CDI) needs are quickly becoming a top issue for healthcare organizations, especially as the push for nationwide interoperability continues to grow. Improving CDI will have long-lasting effects on the...

HIMSS, AMDIS Suggest Ways CMS Can Reduce Administrative Burden

by Kate Monica

In a recent letter to CMS, HIMSS and the Association of Medical Directors of Information Systems (AMDIS) offered suggestions to reduce administrative burden on providers as part of the CMS Patients Over Paperwork Initiative. The Patients...

Google Expands EHR Project Leveraging AI, Voice Recognition

by Kate Monica

Google is looking to expand an early-stage EHR project part of the Google Brain healthcare group that will leverage artificial intelligence (AI) and voice recognition software to streamline clinical documentation and EHR use for providers,...

HIMSS Suggests CMS Reduce Administrative Burden of eCQM Reporting

by Kate Monica

In a recent letter to CMS Administrator Seema Verma, HIMSS recommended several ways the federal agency can improve electronic clinical quality measure (eCQM) development, implementation, and reporting to reduce administrative burden on...

Outdated Regulatory Requirements Key Physician Burnout Cause

by Elizabeth Snell

Regulatory reform allowing clinicians to cut down on their documentation requirements would improve accuracy, enable better use for research, and help cut down on overall physician burnout, according to recent research published in the...

AHIMA Fuels Clinical Documentation Improvement with New Toolkits

by Elizabeth Snell

Clinical documentation improvement (CDI) helps healthcare organizations capture meaningful data for improved quality reporting and clinician productivity. In an effort to ensure that the entire patient record is documented properly, AHIMA...

Physician Burnout Is a Problem at 83% of Healthcare Organizations

by Kate Monica

Eighty-three percent of clinicians, clinical leaders, and healthcare executives view physician burnout as a problem at their organizations, according to findings in a New England Journal of Medicine (NEJM) Catalyst spring 2018 report about...

Lean Methodology Reduces Provider EHR Use by 1 Hour per Day

by Kate Monica

Utilizing Lean methodology to redesign inefficient, first-generation EHR systems can help to improve clinical documentation, boost provider satisfaction, and cut provider EHR use by almost one hour per day, according to new research...

Mayo Clinic to Cut Medical Scribe Staff Ahead of Epic EHR Go-Live

by Kate Monica

In anticipation of its Epic EHR launch, Mayo Clinic has offered about 400 medical transcriptionists the option to either take voluntary separation packages or look for other jobs as the health system no longer requires their...

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