Ron Sterling, HITECHAnswers
“With paper exam notes, the doctor and staff record information and the note reflects what they recorded. Unfortunately, EHR based notes may not be as direct.
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Marla Durben Hirsch, FierceEMR
“Using an automatic alert system in providers’ EHR systems “significantly” increases the documentation of previously unknown patient problems, which could potentially facilitate quality improvement.
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Wright A et al, J Am Med Inform Assoc, 2012
Background
Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date.
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Don Fluckinger, SearchHealthIT
“In its 65th Interim Meeting in New Orleans, the American Medical Association’s House of Delegates voted to vigorously oppose implementing ICD-10 across health care, as mandated by the Centers for Medicare and Medicaid Services (CMS). AMA leadership will now assess just how it will try to stop the new disease coding set, scheduled to replace ICD-9 on Oct. 1, 2013.
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Carl Natale, ICD10 Watch
“In a recent conversation, ICD-10 trainer and consultant Kristi Stanton told me that it’s going to be a significant issue for ICD-10-PCS coding. Thus it’s a huge challenge for hospitals. The impact won’t be as big for physicians in medical practices.
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Beth Walsh, CMIO
“Representatives from two facilities discussed the magnitude of ICD-10 implementation during an Oct. 27 town meeting session at CHIME11, the Fall CIO Forum.
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Bryan Vartabedian, 33 Charts
“I saw it begin to happen in the ’90′s. Residents came to rounds with their daily notes produced on a word processor. The notes were impressive. Legible, lengthy and meticulously detailed at first glance.
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John Moehrke, Healthcare Security/Privacy
“Sometimes one needs to have both a Digital Signature and protect the content with Document Encryption. The Digital Signature (DSG) content profile from IHE provides the Digital Signature.
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Ken Terry, FierceHealthIT
“Steve Jobs’ passing last week has triggered myriad reflections on his immense contribution to the modern world. While much emphasis has been placed on Apple’s recent trendsetting products–the iPod, iPhone and iPad–the signal contribution of Apple under the leadership of Jobs and Steve Wozniak was to make the personal computer practical and useful.
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Gearing P et al, Journal of Healthcare Information Management, 20(4)
As technology becomes more sophisticated in healthcare, there is increasing need to measure its impact on key quality indicators, such as error reduction, patient safety, and cost-benefit ratios. When a product is designed to decrease medical errors, the baseline error rate must be determined before implementation to accurately measure the impact. Given the opportunity to adopt a technology that would eliminate the need to manually document vital signs, a large Florida hospital decided to measure the current process and error rate of vital signs documentation.
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Carl Natale, ICD10 Watch
“After I wrote about what concerns shared by healthcare providers inspired by ICD-10 implementation, I posted a question on our LinkedIn Group.
“What concerns you most about the ICD-10 transition?”
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Hahn KA et al, American Journal of Medical Quality, 26(4)
The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates.
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CMIO
“Exception situations” can enable clinicians to get around limitations of structured data during clinical documentation in an EHR, but must be handled carefully to avoid errors, according to a case report published online June 14 in the Journal of the American Medical Informatics Association.
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Zheng K et al, J Am Med Inform Assoc, 2011
Unpredictable yet frequently occurring exception situations pervade clinical care. Handling them properly often requires aberrant actions temporarily departing from normal practice. In this study, the authors investigated several exception-handling procedures provided in an electronic health records system for facilitating clinical documentation, which the authors refer to as ‘data entry exit strategies.’ Through a longitudinal analysis of computer-recorded usage data, the authors found that (1) utilization of the exit strategies was not affected by postimplementation system maturity or patient visit volume, suggesting clinicians’ needs to ‘exit’ unwanted situations are persistent; and (2) clinician type and gender are strong predictors of exit-strategy usage.
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Janet Dillione, AOL
“Copy-and-paste, templates, macros, checked-boxes and other documentation shortcuts can provide valuable efficiency to doctors and nurses alike. But when it comes to patients’ medical records, there is a fine line between convenience, comprehensiveness and risk.
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Herzberg S et al, International Journal of Medical Informatics, 2011
PURPOSE:
Medical documentation is often incomplete. Missing information may impede or bias analysis of study data and can cause delays. In a single source information system, clinical routine documentation and electronic data capture (EDC) systems are connected in the hospital information system (HIS). In this setting, both clinical routine and research would benefit from a higher rate of complete documentation.
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Gretchen Henkel, The Hospitalist
“Doctor, please clarify: Is this type of congestive heart failure acute or chronic, systolic or diastolic?” Most hospitalists have had patients’ charts flagged with these types of queries. And no, the people who write the questions are not trying to be difficult.
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Rachel Fields, Hospital Review
“ICD-10 will impact productivity of healthcare organizations on many levels, slowing the process of documentation, entering new codes and payor communication, according to an AAPC release.
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Ståhl Y et al, Journal of Nursing Management, 19(2)
Aim
To investigate how nurses and physicians in the Child and School Health Services view the documentation and transfer of health information. Another aim concerns their perceptions of a nationally standardized electronic health record.
Background
Problems of mental health among children and adolescents currently pose one of the greatest challenges facing all European countries. The continuity of health work demands that all health information follow the child’s development, disregarding the organizational arrangement.
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Rosenbloom ST et al, J Am Med Inform Assoc, 18(2)
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability.
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