The clinical burden of documentation

KevinMD

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 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.

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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 Notes

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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: […].

Taking The Sting Out of Patient Care Documentation

Electronic Health Reporter

The article Taking The Sting Out of Patient Care Documentation appeared first on electronichealthreporter.com. 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.

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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.

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.

Optimizing Process and Document Automation in Healthcare

Electronic Health Reporter

The article Optimizing Process and Document Automation in Healthcare appeared first on electronichealthreporter.com. Editorial Document Automation in Healthcare healthcare automation Nintex patient admissions Physician contract management

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FHIR Documents (and other stuff)

HAY on FHIR

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. There’s a lot more to say about documents in FHIR – but hopefully this describes the basics.

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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 Management

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Creating documents in clinFHIR 

HAY on FHIR

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. Note the Document tab in the middle pane (next to the Graph).

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Study: Examining the Clinical Documentation Improvement Landscape

Electronic Health Reporter

When hiring professionals for clinical documentation improvement (CDI) programs, managers seek candidates with a background in both clinical and health information management (HIM) knowledge—challenging a common perception that a clinical background alone is sufficient, according to a recent survey by the American Health Information Management Association (AHIMA). The article Study: Examining the Clinical Documentation Improvement Landscape appeared first on electronichealthreporter.com.

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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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

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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. MHDS is published for public comment. This is the first of two Public Comment periods, with the next one this spring.

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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.

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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

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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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.

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Senators demand Cigna, Optum turn over documents on insulin prices

FierceHealthIT

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

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Robotic Process Automation Improves Poor Document Compliance

Perficient

This blog examines how robotic process automation (RPA) can improve document compliance. Keeping sites in compliance with their required documentation is an ongoing battle for every sponsor and CRO. Automating notifications related to upcoming and past-due document deadlines.

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. Initially Document Sharing was about 'historic' documents. FHIR has a Document model.

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2018 Annual Report Documents Changes in Medical Staff Credentialing

HealthStream

It documents many ways in which the credentialing and privileging industry is changing at a rapid pace This guest blog post from VerityStream, A HealthStream Company, announces that the 2018 Annual Report on Medical Staff Credentialing has been released.

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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.

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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. Each document shared is described by metadata.

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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

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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

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Basics of doing Document Sharing Query right

Healthcare Exchange Standards

Mostly they keep trying because the most basic query is just asking for all documents available for a given Patient. These are useful, just not very primary for a general purpose Document Consumer. Where these classifications are useful to a Document Consumer.

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CMS new rule: Experts weigh in on big changes to clinical documentation, EHRs and interoperability

Mobi Health News

The "historic changes" announced late yesterday by the Centers for Medicare & Medicaid Services, promising big adjustments to its policies around the Physician Fee Schedule and the Quality Payment Program, already have the healthcare industry talking

CMS new rule: Industry reacts to big changes to telehealth, clinical documentation, and interoperability

Mobi Health News

The "historic changes" announced late yesterday by the Centers for Medicare & Medicaid Services, promising big adjustments to its policies around the Physician Fee Schedule and the Quality Payment Program, already have the healthcare industry talking

CAQH CORE Outlines Five Areas to Improve Medical Documentation Attachments

hea!thcare innovation - Clinical IT

About 84 percent of attachments are currently being sent manually, leading to misinformation and delays

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Multiple formats of the same Document content

Healthcare Exchange Standards

I propose that “The most technically advanced” document format be considered the Prime, with all of the other formats considered Transforms (XFRM) from that prime document. Thus if the Document Source can create a C-CDA 2.1; As proof, FHIR Documents will re-open this discussion.

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House Dems demand documents on DOJ’s position in ACA case 

FierceHealthIT

The political back-and-forth about the legal fight over the legality of the ACA continued this week, as top Democrats demanded documents on the Trump administration’s position in the matter.

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Improving Document Exchange Response with Asynchronous FHIR API

Healthcare Exchange Standards

This is just one step in the overall interaction that one does with a Cross-Community Document Exchange (XCA). Thus this Patient Discovery can take minutes before the second step of Query for Documents can happen. Thus the Query for Documents can be limited to just those 10.

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Medicare made $23B in improper payments in 2017 due to documentation errors, GAO finds

FierceHealthIT

Medicare made more than $23 billion in improper payments in 2017 due to insufficient documentation, according to a new Government Accountability Office (GAO) report. The GAO also found that Medicaid paid out more than $4 billion for services that were not fully or properly documented

IHE ITI Document Sharing Metadata Handbook Published for Public Comment

Healthcare Exchange Standards

IHE IT Infrastructure Handbook Published for Public Comment The IHE IT Infrastructure Technical Committee has published the following new handbook for public comment in the period from June 13 through July 13, 2018: Document Sharing Metadata - Rev. The document is available for download at [link]. Those implementing or improving their XDS or XCA community are the intended audience of this Handbook. As a Handbook, it strives to inform on critical aspects of Metadata management.

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How Technology will transform the Future of Clinical Documentation

Lloyd Price

Dr Simon Wallace looks at how technology will transform the future of clinical documentation. As the NHS turns 70, it’s time we considered how Britain’s world-leading health service has transformed clinical documentation since its inauguration back in 1948.

Real-World Evidence is What Pharma Needs Now to Help Cure Lung Cancer

Healthcare IT Today

Administration Analytics/Big Data Clinical Health IT Company Healthcare IT HIM Hospital - Health System IT Revenue Cycle Management CDI CDQI Ciox CIOX Health Clinical Documentation Improvement Clinical Documentation Quality Improvement Healthcare Scene Featured HIM Scene MPI Revenue Leakage

Microsoft, Nuance developing ambient and AI technology to tackle doctors' documentation headaches

FierceHealthIT

Tech giant Microsoft is teaming up with Nuance Communications to use technology to solve a big pain point for doctors—too much time spent on documenting and administrative tasks. The two companies are collaborating to use ambient technology combined with AI, automation and cloud computing to create an exam room where the clinical documentation "writes itself

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