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 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 KevinMD.com. Search thousands of physician, PA, NP, and CRNA jobs now.

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.

EHR 86

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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 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.

76

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.

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.

EMR 62

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.

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 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.

82

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.

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

KevinMD

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 KevinMD.com. Search thousands of physician, PA, NP, and CRNA jobs now. Learn more. Tech Health IT

EMR 297

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.

EMR 72

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).

FHIR 60

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

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.

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

EHR 220

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.

EHR 277

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. 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.

FHIR 69

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.

FHIR 77

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.

52

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.

EMR 51

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.

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 electronichealthreporter.com.

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. Needless to say, it’s hard to talk about new, […].

EHR 70

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

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

190
190

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

EHR 65

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.

FHIR 40

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.

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.

HIE 52

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

67

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 electronichealthreporter.com. 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.

HIPAA 76

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.

52

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

204
204

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.

FHIR 40

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

EMR 40

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

173
173

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

65

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. Let me explain the next level of Document Sharing (XDS, XCA, MHD) Query As part of the metadata handbook discussion, Charles has clarified in a very elegant way a " Best Practice " for leveraging the XDS/XCA/MHD Query, vs local processing of the resulting document entry/reference Metadata, to achieve the best results.

HIE 43