Clinical Documentation

Transitioning Paper to Electronic Health Records

December 21, 2012    
webinar

How Do You Tame Unruly Meaningful Use Measures?

November 28, 2012     David Raths
blog
Among key meaningful use challenges for physician offices are vendor product nuances, workflows that must be redesigned, and staff roles that needed to be redefined.

Light at the End of the Tunnel in the Free-Text-Structured Documentation Controversy?

November 14, 2012     Mark Hagland
blog
One thing seemed clear last week at the AMIA 2012 Conference: physician informaticists are helping to move the discussion—and the solutions—forward towards new solutions in the physician documentation arena

The Health Story Story Continues

November 7, 2012     David Raths
blog
Health Story is supporting a project team within HL7 that is working to create a standard for “Patient Authored Documents” using the HL7 CDA standard.

LIVE from the AMIA 2012 Symposium: Physician Documentation: Parsing the Narrative/Structured Documentation Tension

November 7, 2012     Mark Hagland
article
As self-created electronic physician documentation replaces transcribed clinical documentation, what are the implications of that shift for physician workflow, efficiency, and clinical effectiveness, and ultimately, for care quality? Those questions were explored by a panel of clinical informaticists, all of whom have engaged in recent research and study of some of these issues. That discussion took place during a Nov. 6 session at the AMIA 2012 Symposium, currently being held at the Chicago Hilton & Towers in downtown Chicago, and sponsored by the American Medical Informatics Association. Not surprisingly, one of the big topics of discussion was the oft-discussed tension between supporting a rich narrative within the patient record, and facilitating EHR-focused efficiency.

Mobile Documentation: Optimizing Technology to Do More with Less

October 22, 2012     Jennifer Prestigiacomo
article
When the University of Missouri Health System sought to optimize its bedside documentation workflows, it chose to enhance its current medication administration devices to allow mobile point-of-care documentation, an innovation that has led to a dramatic advance in speed to documentation of patient data, ultimately improving patient care.

What Happens When Your EMR Coding Wizard Loses its Magic?

September 11, 2012     Pete Rivera
blog
You cannot make a blanket policy to say that the coding software will be used exclusively. This is like telling a pilot to trust their instruments, although the ground is getting closer and closer.

Common IT Platform Key to Iowa Alliance

September 10, 2012     David Raths
blog
An announcement in late June by four of Iowa’s leading healthcare organizations signals a trend we are likely to see much more of in the near future: competitors cooperating on care coordination and quality measurement platforms, which requires a greater level of collaboration among CIOs.

A Tragic Air Crash Helps Define HCIT Safety Needs (Part 1)

July 20, 2012     Joe Bormel
blog
Earlier this month, the final crash report on AF447 was released. The implications for HCIT safety, usability and hazard governance are profound. The crash occurred on June 1, 2009. All 228 people onboard were killed, and it took three years to unravel the mysterious components of the story. ... read more...

Will Rory Staunton’s Story Be Your Hospital Emergency Department’s Story?

July 17, 2012     Mark Hagland
blog
The tragic outcome in a New York sepsis case involving a promising young 12-year-old ignites interest, and thousands of comments, in The New York Times.

EHR’s JUST DON’T WORK!

July 11, 2012    
blog
Let’s face it; most EHR’s are designed for primary care physicians. The idea is to continue to grow the patient data in the record each time you see a patient. Eventually you end up with a robust history and clinical data that can be used to improve the quality of care. However, specialists get a patient referral, they see the patient two or three times and they are sent back to their primary care.
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