The clinical burden of documentation


The purpose of clinical documentation is to efficiently communicate critical data to peers in a readable fashion while meeting compliance and billing requirements. This documentation should not represent a data dump. Physicians continually increase our dependence on technology as the digital age deluges us with data. Accessing the right information at the right time is […]. Find jobs at Careers by Search thousands of physician, PA, NP, and CRNA jobs now.

Ambient Clinical Voice, NLP, and EHR Auto Documentation

Healthcare IT Today

This shouldn’t come as a surprise since if ambient clinical voice is effective, then it could solve so many of the EHR documentation features that put such a burden on physicians in healthcare.

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The Auto Documentation Telehealth Solution Will Be a Big Winner

Healthcare IT Today

AI/Machine Learning Ambulatory C-Suite Leadership EMR-EHR Health IT Company Healthcare IT Hospital - Health System LTPAC Telemedicine and Remote Monitoring Ambient Clinical Voice NLP Nuance Nuance Dragon Ambient eXperience telehealth Telehealth Documentation telemedicine Telemedicine Documentation Voice RecognitionLast week I started a project to create a list of all of the telehealth options out there.

Taking The Sting Out of Patient Care Documentation

Electronic Health Reporter

The article Taking The Sting Out of Patient Care Documentation appeared first on Editorial healthcare documentation HEDIS IKS Health MIPS patient care documentation Shane PengThis article is copyrighted strictly for Electronic Health Reporter. Illegal copying is prohibited. By Shane Peng, MD, chief clinical services and innovations Officer, IKS Health.


Microsoft to Integrate Epic EHR and Nuance Automated Documentation with Teams Tool

Healthcare IT Today

Microsoft has announced two deals leveraging its Teams tool which could cast a long shadow over the rapidly evolving telehealth sector. The tech giant signed an agreement with Epic under which the EHR vendor would become the first such organization to use the Teams connector function.

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Physicians May Be Documenting Care That They Don’t Provide

Healthcare IT Today

A newly-published study suggests that physicians may not be performing all of the services they document. While the study tracked medical residents rather than physicians who had completed their training, researchers seem to have concluded that their problems with adequate documentation might point to problems affecting all physicians.

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Optimizing Process and Document Automation in Healthcare

Electronic Health Reporter

The article Optimizing Process and Document Automation in Healthcare appeared first on Editorial Document Automation in Healthcare healthcare automation Nintex patient admissions Physician contract managementThis content is copyrighted strictly for Electronic Health Reporter. By William Sandy, digital marketing, Nintex. The healthcare industry is already well on its way to digital transformation.


Doctors are burdened by documentation, are AI scribes the answer?

Mobi Health News

Matthew Fradkin, a pediatrician at Swedish Primary Care and Providence St. Joseph, discusses his work implementing an ambient scribe in his workflow at HIMSS20 Digital.

Just because EMRs can document everything doesn’t mean they should


It's always kind of a surprise when you read a patient's chart, and you see an examination of a body part they just don't have. Just the other day, I was reading a consult note on a patient of mine who had been seen by a subspecialist for evaluation of a serious issue, and I […]. Find jobs at Careers by Search thousands of physician, PA, NP, and CRNA jobs now. Learn more. Tech Health IT

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If This Is Human Documentation, Give Me Sweet, Nonjudgmental AI

Healthcare IT Today

AI/Machine Learning Ambulatory Analytics/Big Data Clinical EMR-EHR Health IT Company Healthcare IT Hospital - Health System IT AI-Driven Medical Records Open Notes Patient Medical Records Physician Documentation VIsit Documentation Visit NotesNot long ago, I wrote about what happened when I requested a digital copy of my medical records from my healthcare provider, Kaiser Permanente.

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Technology Solutions for Optimizing Clinical Documentation

Healthcare IT Today

Clinical documentation is widely known to be a time-consuming task. Much of that documenting rests on the shoulders of nurses, who use health information technology to help juggle their many roles: […]. Clinical EMR-EHR Health IT Company Healthcare IT Hospital - Health System Clinical Documentation Elsevier Evidence Based Care Fragmented Care Jessica Campbell LogicStream Health Nurse Documentation Tiffany McCauley

Webinar on Document Sharing HIE on FHIR

Healthcare Exchange Standards

Webinar recording is available that covers the Document Sharing Health Information Exchange (HIE) on FHIR.

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Telehealth Documentation

Telebehavioral Health Institute

How to Stay Out of Hot Water: Telehealth Documentation! Easy 3-Part TBHI Online Webinar Series) 6 CE Hours Available Have you updated your telehealth documentation to address recent state and association specific requirements? Reviewing your documents has never been easier. The post Telehealth Documentation appeared first on TBH Institute Blog.

Google demos its EHR-like clinical documentation tool

Mobi Health News

News of the tool, currently in clinical pilots, comes a week after reports circulated that Google was working with healthcare system Ascension on a controversial project involving patient data

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Mobile Health Document Sharing (MHDS) Profile

Healthcare Exchange Standards

This profile shows how to build a Document Sharing Exchange using IHE profiled FHIR® standard, rather than the legacy IHE profiles that is dominated by XDS and HL7® v2. This profile will assemble profiles and define a Document Registry. These IHE profiles include support for patient identification, health document location and retrieval, provider directories, and the protection of privacy and security. The actor that is specific to this profile is a Document Registry.

Ambient documentation with Epic helps reduce clinician burnout at Monument Health

Healthcare IT News - Telehealth

"All organizations are looking for ways to engage the patient, and adopting ambient documentation is the first step to not only engaging but also improving upon their experience." “Also, our physicians use Nuance Dragon Medical One to document in the EHR via voice.

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Creating documents in clinFHIR 


I did a demo of clinFHIR for the Clinicians on FHIR group that will be meeting at the Working Group Meeting next week, and completely forgot to talk about creating/viewing documents in clinFHIR using the scenario builder. This is functionality that has been around for a while, and allows you to create a FHIR document by adding a Composition resource to the scenario, and then linking up the other resource to it. Note the Document tab in the middle pane (next to the Graph).


FHIR Documents (and other stuff)


We’d likely think of a clinical note as a Document – a summary at a point in time that should be persisted in the clinical notes, and that leads us to the Composition resource. This text is important as it is used to render the overall document into a human readable form (along with the text from the Patient resource and the Composition itself – see the formal description of this). There’s a lot more to say about documents in FHIR – but hopefully this describes the basics.


Expand your search using AWS native services to identify, comprehend and securely store documents.


The document debacle. Companies continue to fight the battle of the age-old problem: paper documents. Adapting to document modernization to expand the ability to search, catalog and protect HIPAAPII data is paramount.


How AI Assistants Are Decreasing the Physician Documentation Burden

Healthcare IT Today

Coming into the year, one of the most exciting technologies I saw coming down the pipe was ambient clinical voice technologies and EHR AI Assistants. I thought this would be a major theme at the HIMSS20 Annual conference. Then, everything blew up included HIMSS20 being cancelled.

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Digital Exchange and Processing of Medical Documentation Key To Success In Value-Based Care

Electronic Health Reporter

With the shift towards value-based care reimbursement models, it has become even more important for providers to be able to digitally share patient clinical documentation with payers […]. This article is copyrighted strictly for Electronic Health Reporter. Illegal copying is prohibited.


Medical documentation AI system Sopris Health raises $3.4M

Mobi Health News

The Denver-based startup designed an AI system that lets doctors capture their conversations with patients and transfer those notes to EHRs.

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Providers Increasing Adoption of AI-Fueled Clinical Documentation Technology

Healthcare IT Today

AI/Machine Learning Ambulatory EMR-EHR Health IT Company Healthcare IT HIM Hospital - Health System IT Revenue Cycle Management Black Book Research Clinical Documentation Improvement Computer Assisted Coding Healthcare Workflow Hospital Case ManagementThe use of computer-assistant coding has been percolating along for a while now but hasn’t taken over the healthcare industry.

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CMS's 2019 proposal makes broad strides in telehealth, interoperability, documentation

Mobi Health News

The Centers for Medicare and Medicaid Services released its new proposed Physician Fee Schedule and Qualified Payment Program updates for 2019, and the announcement includes some big strides forward in promoting digital health technology, including widened telemedicine coverage, an overhaul of documentation requirements, and a new focus on interoperability

AHIMA Develops Tools To Help Clinical Documentation Integrity Professionals During COVID-19

Electronic Health Reporter

With clinical documentation integrity (CDI) professionals playing a key role in efforts to “flatten the curve” of the COVID-19 pandemic, the American Health Information Management Association (AHIMA) has developed tools designed to ease administrative burdens […]. The article AHIMA Develops Tools To Help Clinical Documentation Integrity Professionals During COVID-19 appeared first on

Study: Provider Experience Affects EHR Documentation Time

hea!thcare innovation - Clinical IT

It’s been widely-referenced that physicians spend large chunks of their days documenting patient encounters using electronic health records (EHRs), and now a new study has pointed to provider experience being a key factor in just how much time

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FCC document suggests Apple may launch new Beddit device

Mobi Health News

The filing is a strong indication the Cupertino tech giant isn't done with standalone sleep monitoring devices


Clinical Documentation Improvement Top Priority for Hospitals

BHM Healthcare Solutions

Editor’s Note: BHM watches health trends and understands the importance of improving clinical documentation and improving the industry. Hospitals are increasingly implementing clinical documentation improvement technologies, according to a Black Book survey. “The need for proper clinical documentation improvement driving quality outcome scores has never been more essential,” said Doug Brown, managing partner of Black Book.


Mobile Health Document Sharing (MHDS) - First Public Comment

Healthcare Exchange Standards

The Mobile Health Document Sharing (MHDS) Profile is a 100% FHIR Document Sharing infrastructure leveraging many IHE FHIR profiles including MHD. Where MHD has historically been an API to an XDS or XCA environment; MHDS introduces a new Central Registry actor and discusses how to build a complete Document Sharing infrastructure using other IHE Profiles. MHDS is published for public comment. This is the first of two Public Comment periods, with the next one this spring.


Cloud Pak and IBM Automation Document Processing: It’s more than AI and ML


As our clients continue their digital transformation journeys, challenges with traditional document capture solutions are coming to the forefront. IBM Automation Document Processing. Imagine a bank receiving and storing bundles of documents related to the opening of a loan.


Treatment based interop is best using Documents

Healthcare Exchange Standards

This position is that for Treatment and Payment the best format for clinical data is Document based. Although publication should be Document based, these documents must be decomposed and analyzed relative to the current Treatment situation. The document must be Authentic and Authenticatible. The document must be complete story of the whole story around that treatment. The Clinical Document meets a set of Principles that all are critical.


Clinical Documentation Tools and Ambient Clinical Voice – Telehealth Features Series

Healthcare IT Today

In this Telehealth Feature Series, we’re going to cover the long list of potential telehealth features available today. As you’re considering your own approach to telehealth, we will provide you a look at all the possible features telehealth companies are offering on the market.

Senators demand Cigna, Optum turn over documents on insulin prices


Leaders of the Senate Finance Committee demanded Cigna and Optum produce critical documents over the pricing of insulin, with a subpoena threat looming


FHIR documents in XDS

Healthcare Exchange Standards

How does one put a FHIR Document into XDS? How does one find a FHIR Document in XDS? XDS, more broadly the whole Document Sharing family, including XDS , XCA , XDR , XDM , and MHD. To learn more on Document Sharing, start here: Eating an Elephant -- How to approach IHE documentation on Health Information Exchange (HIE) So the Document Sharing family is a Content Agnostic mechanism for sharing Patient specific Documents. FHIR has a Document model.


Through AI text chats, Sopris Health's new app saves time on clinical documentation

Mobi Health News

Launched today, Sopris Health uses voice tech and simple Q&As to wrap up notes in less than a minute


HIPAA Waiver Offers Physicians Opportunity To Engage Patients In New Ways, But Documentation Is Key

Electronic Health Reporter

The article HIPAA Waiver Offers Physicians Opportunity To Engage Patients In New Ways, But Documentation Is Key appeared first on This article is copyrighted strictly for Electronic Health Reporter. Illegal copying is prohibited. The HIPAA waiver issued for telemedicine during COVID-19 is a game-changer for physicians now that CMS says virtual visits are reimbursable.


Documents, anonymous source describe Amazon's wearable, app for voice-based emotion detection

Mobi Health News

Codenamed Dylan, the system could be used to help an individual better communicate with others


Big Tech: Microsoft. Nuance Plan Tech Which Creates Documentation For Physicians

Healthcare IT Today

For a while now, since AI applications have begun to hit the mainstream, there’s been talk of the day when such tools might take over patient documentation and free up physicians to actually look at their patients. AI/Machine Learning Ambulatory Analytics/Big Data Clinical EMR-EHR Health IT Company Healthcare IT IT AllScripts Ambient Clinical Intelligence Microsoft Microsoft Azure Natural Language Processing Northwell Health Nuance Smart Healthcare Documentation Stanford Medicine

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IHE Document Sharing (XDS) Metadata management Handbook

Healthcare Exchange Standards

The IHE IT Infrastructure Technical Committee has published a new Handbook as of August 20, 2018: Document Sharing Metadata The above document is available for download at [link] or at User Handbooks. The full IHE formal announcement The Document Sharing profiles from IHE including XDS and XCA, enable a Community to share Patient specific medical documents. This is described in the Enabling Document Sharing through IHE Profiles white paper (HIE using IHE).

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Nearly All Healthcare Execs Expect To AI Improve Revenue Cycle Management In The Near Future

Healthcare IT Today

A new survey has found that despite setbacks created by the COVID-19 pandemic, AI use is common in healthcare organizations, and could be all but universal within five years.