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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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...

Improving EHR Use, Interoperability, Optimization at HIMSS17

by Kyle Murphy, PhD

EHR adoption is at an all-time high after healthcare organizations and providers completed EHR implementation projects over the past several, so it should come as no surprise that numerous educational opportunities health IT’s most recognized...

Study Raises Doubts about Clinical Documentation Accuracy

by Kate Monica

Researchers at the University of Michigan sought to investigate whether patient-reported eye symptoms were recorded as part of clinical documentation in EHR systems. As part of a study published in JAMA Ophthalmology, Valikodath et al. compared...

WEDI Clarifies Clinical Documentation in 2017 ICD-10 Guidance

by Sara Heath

The Workgroup for Electronic Data Interchange (WEDI) has released an issue brief on clinical documentation and the 2017 ICD-10 Official Guidelines. The 2017 guidelines include a specific provision about clinical documentation. In guideline 19,...

Clinical Decision Support Decreases Sepsis Mortality in AL

by Kyle Murphy, PhD

A pair of clinical informaticist consultants found clinical decision support (CDS) systems to have a positive impact on identifying instances of sepsis and reducing sepsis mortality at an Alabama hospital. According to the research published...

Using Epic EHR to Survive a Perfect Storm of Regulation

by Kyle Murphy, PhD

Much of the attention focusing on the Epic implementation going on at Partners HealthCare focuses on EHR adoption in acute-care settings, but its impact will be especially valuable for its non-acute or post-acute care partners throughout Massachusetts....

Does Speech Recognition Aid Clinical Documentation Improvement?

by Kyle Murphy, PhD

Despite the availability of speech recognition software and natural language processing over the past two decades, research shows limited evidence proving these technologies to have a clearly positive impact on clinical documentation improvement....

Leveraging Health IT for Clinical Documentation Improvement

by Kyle Murphy, PhD

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...

Tips for Approaching Clinical Documentation Improvement

by Sara Heath

Clinical documentation is an important bridge between healthcare coders and physicians. The accurate documentation of health services provided benefits healthcare organizations not only with regard to revenue cycle, but with accurate care delivery...

Why Prioritizing Usability Effects Better Ambulatory EHR Use

by Kyle Murphy, PhD

Winona Health in rural Minnesota is celebrating a major health IT milestone after having received recognition from HIMSS Analytics for its ambulatory EHR use. The rural community health center counts itself among the top-seven percent of healthcare...

ACP Offers EHR Clinical Documentation Improvement Guidelines

by Stephanie Reardon

Long trails of information can lead to difficulties in finding and understanding the most important information within a patient’s records at the point of care. The American College of Physicians (ACP) has released a report detailing recommendations...

Case study: How clinical analytics helps with meaningful use

by Jennifer Bresnick

Whether a healthcare organization is attesting to Stage 1 or Stage 2 of meaningful use this year, the process may not be entirely intuitive for physicians and other clinicians responsible for documenting patient care.  At Massachusetts General...

Are clinicians ready for ICD-10 documentation requirements?

by Sponsored Content

Over the past two years, hospitals have invested in modifying applications and workflows to fit the demands of ICD-10. And many have ramped up training on the detailed documentation that the new coding system requires. But a February survey by...

Tackling claims processing, payment management bottlenecks

by Kyle Murphy, PhD

Healthcare organizations of all sizes find themselves in a particularly challenging spot when it comes to reimbursement. Although reimbursement is beginning to shift away from volume to value, much of their revenue today still depends on the...

How can IT, automation help improve healthcare revenue?

by Kyle Murphy, PhD

Since the passing of the Health Information Technology for Clinical and Economic Health (HITECH) Act, the healthcare industry has spent most of its time and resources on selecting, implementing, and optimizing EHR systems. While EHR adoption...

How are federal policies changing reimbursement strategies?

by Kyle Murphy, PhD

A shift from fee-for-service to pay-for-performance has healthcare organizations reconsidering how their clinical practices will impact their bottom lines moving forward as providers assume greater and greater accountability. With most health...

Understanding claims in the context of the revenue cycle

by Kyle Murphy, PhD

For hospitals and physician practices to ensure that their claims are paid, they must first understand how the different components of claims management affect reimbursement. “Whether you call it revenue cycle or protecting your reimbursement,...

AHIMA Releases Recommendations For Coding Compliance Policies

by Jennifer Bresnick

A white paper produced by the American Health Information Management Association (AHIMA), offers guidance on identifying source documents and clinical documentation that make up the core of a designated clinical documentation set.  AHIMA...

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