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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Nearly 70% of Physicians Suffering Stress Related to Health IT Use

by Kate Monica

Almost 70 percent of physicians who use EHR technology during patient care delivery have experienced stress as a result of the demands of health IT use, according to a recent JAMIA study. Health IT-related stress can contribute to...

Simplifying Clinical Documentation to Cut Administrative Burden

by Kate Monica

Hawaii Pacific Health is working to prevent physician burnout and reduce administrative burden on providers by cutting out the aspects of clinical documentation and EHR use that clinicians find least useful. In a recent New England...

Collaborating With EHR Vendors for Continuous EHR Optimization

by Kate Monica

Healthcare organizations looking to dramatically improve their clinical and administrative processes through health IT use can choose one of two options: EHR optimization or EHR replacement. Some healthcare organizations opt to invest in...

Using EHR Voice Recognition to Improve Clinical Documentation, Usability

by Kate Monica

EHR tools with voice recognition capabilities can help to reduce data entry duties for healthcare providers and free up time for face-to-face interaction with patients. Hospitals and health systems are increasingly integrating voice...

EHR System Transformation at Center of Penn Medicine Initiative

by Kate Monica

Penn Medicine recently launched an initiative intended to transform EHR systems into more interactive, intuitive tools to ease provider burden, improve patient health outcomes, and boost clinical efficiency. “We recognize that EHRs...

EHR Tools Collecting Social Determinants of Health Data Need Work

by Kate Monica

Integrating social determinants of health (SDH) data into EHR systems may help providers address the economic and social risks that negatively affect patient health. However, a recent Annals of Family Medicine study by Gold et al....

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,...

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