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In this era of value-based care, clinical documentation takes on an even greater sense of urgency. A failure to properly capture patient care leads to a host of headaches that can quickly mushroom into serious consequences.
This month’s E-News Exclusive spotlights how one health care organization took control of its documentation by implementing a plan that included collaboration between departments, user input, and top-shelf technology. It’s a model that’s led to impressive results.
— Lee DeOrio, editor |
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Strong Leadership, Clinical-IT Collaboration Lead to CDI Success
By David Lareau
Clinical documentation can be a tremendous source of physician frustration. Capturing patient information can be cumbersome, chart notes don’t always reflect a patient’s complete clinical status, and completed records are often difficult to translate for quality reporting, reimbursement, and chronic care management.
However, with strong clinical leadership, collaboration between clinical and IT, flexible documentation tools, and well-thought-out processes, clinical documentation has the potential to improve the quality of patient care and physician productivity and satisfaction.
Phoenix Children’s Hospital (PCH) realized these benefits after rolling out a clinical documentation improvement (CDI) program across its ambulatory health clinics.
Here’s how they did it.
Full story » |
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AMIA Calls on HHS to Decouple Clinical Documentation and Administrative Requirements
In comments recently submitted to the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS), AMIA recommended that Health and Human Services (HHS) orient its documentation burden reduction strategy towards a long-term goal of decoupling clinical documentation from billing, regulatory, and administrative compliance requirements.
In late November 2018, ONC and CMS released its draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.” The strategy, which is required by the 21st Century Cures Act, outlines three overarching goals that aim to reduce clinician burden: Reduce the effort and time required to record health information in EHRs for clinicians; reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations; and improve the functionality and intuitiveness of EHRs.
The draft strategy laid out four focus areas—clinical documentation, HIT usability and user experience, EHR reporting, and public health reporting—setting forth dozens of recommendations to reduce administrative and regulatory burden.
Read more » |
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Excel Medical Technology to Be Featured in Epic
Excel Medical, an innovator in Medical Device Integration (MDI) and analytics, announces its solutions offering for Epic clinical applications that extend beyond traditional MDI. Excel Medical uniquely delivers real-time physiological data (eg, waveforms, vitals, clinical alarms) into Epic’s clinical workflows through deep integration across Hyperspace, Canto, Haiku, and Rover applications. Excel’s solutions simplify the health system enterprise using a single platform supporting patient monitors, medical devices, alarm management, digital cardiac monitor documentation, and real-time physiological surveillance resulting in taming of the traditional chaos of IT environments. Excel’s enterprise MDI platform improves clinical workflows and clinical team satisfaction and reduces unexpected hospital deaths by providing greater access and assimilation of real-time patient data. Learn more »
nThrive Announces Machine Learning Technology Offering
nThrive, an independent Patient-to-Payment solutions company, announces the launch of their new machine learning technology that expands Charge Capture Audit (CCA) to cover nonacute settings. nThrive can now offer CCA in both acute care and the ambulatory professional settings. The CCA Professional Solution uses machine learning to identify missed charges based off algorithms, allowing hospitals to capture additional revenue. nThrive leverages its broad market presence to mine billing data to identify patterns in charging practices. With this information, the company offers a predictive algorithm to identify missing charges. Learn more »
Patientory Puts Patients in Control of Their Digital Health Care
Patientory Inc announces a consumer application that gives patients ownership of their medical records and the ability to directly share their daily health data with physicians. The app syncs health data such as allergies, activity, blood pressure, weight, and more between all connected devices, including centralized EMRs. The app serves as a cross-device hub in which users can view their health information, securely provide it to their preferred health care providers, and if desired, share their experiences with fellow patients. Patientory includes a social community component within the app to help users support one another, allowing users with similar conditions to ask questions, get recommendations, and share their experiences. The app’s software is built on blockchain technology, enabling full HIPAA compliance on a secure platform. Patientory is available at no charge on the Apple Store. Learn more » |
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Constructing a Career in Coding
For those looking to snag that elusive first coding position, experts suggest focusing on everything from the right academic mix to sound résumé building. Read more »
TPE Program Sets Sights on Improper Claims
Learn the details behind the Target, Probe, and Educate effort, which can make life miserable for organizations suspected of failing to meet Medicare criteria. Read more »
Privacy With a European Flair
More powerful than HIPAA, the European Union’s General Data Protection Regulation may have an effect on these shores. Read more »
‘Stupid’ Program Gets Results
To simplify documentation processes, a Hawaii health system took a radical in-house approach—it listened to staff. Read more » |
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Bet on a Beneficial Experience at HEALTHCON
By Heather Hogstrom
AAPC is returning to Las Vegas for HEALTHCON 2019, the largest revenue cycle management event of the year. Slated for April 28 to May 1 at Caesars Palace, the conference offers the opportunity for entertainment as well as education, including an a cappella concert by Eclipse 6. Attendees resisting the siren call of shows, shops, and slots can enjoy a keynote by Karen DeSalvo, MD, MPH, MSc, on the public health changes she’s overseen. Other noteworthy sessions include an interactive discussion on the upcoming changes to the E/M Documentation Guidelines, and cautionary health care fraud tales from Office of Inspector General investigations.
Read more » |
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MD Anderson Cancer Center Appeals $4.3 Million HIPAA Fine
The University of Texas MD Anderson Cancer Center has filed a lawsuit arguing that a HIPAA penalty Health and Human Services levied against it was unlawful, reports GovInfoSecurity.
Patent Filings Hint at Apple’s Potential Move Into Managing Health Care Records
Patent applications indicate Apple is interested in aggregating consumers’ health data in one place on their mobile devices, according to FierceHealthcare. |
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