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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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...

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...

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