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 improve...


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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, according...

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 providers...

Outdated Regulatory Requirements Key Physician Burnout Cause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 Annals...

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 released...

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 burnout...

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 published...

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 services. Mayo Clinic’s...

EHR Clinical Documentation Differs Between Nurses, Physicians

by Kate Monica

Physicians and nurses note very different concepts in EHR clinical documentation during patient visits, according to a recent study by researchers at the in the International Journal of Medical Informatics. Boyd et al. conducted the study to...

Family Physician EHR Use Outweighs Provider-Patient Interaction

by Kate Monica

Primary care physicians spend more time on EHR use than they spend interacting with patients face-to-face during clinic visits, according to a new study in Family Medicine. Young et al. conducted a cross-sectional, observational study of family...

CMS Modifies E/M EHR Clinical Documentation Requirements

by Kate Monica

The American College of Physicians (ACP) recently applauded a CMS decision to change EHR clinical documentation requirements. Teaching physicians can now verify medical student documentation in a patient’s EHR related to evaluation and...

Poor Staff Training Contributed to Trying Cerner Implementation

by Kate Monica

Workarounds, poor staff training, and problems with system stabilization and revenue cycle management were the primary causes of complications during a Cerner implementation at Medical Center Health System (MCHS). MCHS President and CEO Rick...

Canadian Physician Suspended for Deceptively Altering Patient EHR

by Kate Monica

A Canadian physician at Quance East Medical Clinic has been suspended for one month and fined $7,484 by the College of Physicians and Surgeons of Saskatchewan after admitting she altered a patient EHR several times in eight months following the...

Scribes Reduce EHR Use, Restore Joy of Practice for Physicians

by Kate Monica

A recent study by Sattler et al. found integrating scribes into primary care clinics can reduce administrative burden associated with EHR use, improve levels of physician satisfaction, and allow for higher quality care. Beginning in 2015, researchers...

EHR Use, Administrative Burden Accelerating Physician Burnout

by Kate Monica

In response to a new study about high levels of physician burnout among family physicians, Ohio State University Wexner Medical Center family physician Donald O. Mack, MD, suggested the recent transition to a value-based care system and increased...

Standardizing Adverse Drug Reaction Data in EHR Documentation

by Kate Monica

A new report published in the Journal of the American Medical Informatics Association (JAMIA) provides a means for improving EHR documentation of adverse drug reactions. “Well-developed documentation standards for EHR systems exist in some...

ONC Chief Keen on Moving Health IT Innovation Beyond the EHR

by Kyle Murphy, PhD

Healthcare interoperability and health IT usability were front and center at the 2017 ONC Annual Meeting in the nation’s capital and indicative on a change that took hold within the federal agency in recent years following its successful...

Newly-Designed Physician EHR Notes May Improve EHR Usability

by Kate Monica

Showing less data in physician EHR notes may produce more benefits for physician productivity, according to a recent study published in the Journal of the American Board of Family Medicine (JABFM). The study by Jeffery Beldon, MD et al. compared...

Ophthalmologists Spend 27 Percent of Patient Visits on EHR Use

by Kate Monica

A new study published in the Journal of the American Medical Association (JAMA) Ophthalmology found ophthalmologists spend 27 percent of a typical patient encounter on EHR use, suggesting a need for EHR usability improvements. The study by Read-Brown...

Primary Care Doctors Spending 6 Hours Daily on EHR Data Entry

by Kate Monica

A new study by the University of Wisconsin and the American Medical Association (AMA) found primary care physicians spend almost six hours on EHR data entry during a typical 11.4 hour workday. Research by Arndt et al. published in the Annals...

Realizing the Benefits of Clinical Documentation Improvement

by Kate Monica

Physician practices and healthcare organizations have been batting around the idea of clinical documentation improvement (CDI) for over ten years. The American Health Information Management Association (AHIMA) has taken a particular interest...

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