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“Hey Alexa, document this patient encounter.” OK, we’re not quite at that point but it’s not that far off.
A recent white paper chronicles how artificial intelligence can be a game-changer, saving physicians time and headaches by capturing the necessary ingredients of a well-constructed patient note.
This month’s E-News Exclusive dives into the findings from the viewpoint of AHIMA President/Chair Katherine Lusk, MHSM, RHIA, FAHIMA.
— Lee DeOrio, editor |
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Artificial Intelligence Is a Game-Changer for Clinical Documentation Integrity
By Katherine Lusk, MHSM, RHIA, FAHIMA
When clinical documentation integrity (CDI) is managed by certified health information professionals, it can lead to improved patient care. That’s why AHIMA and 3M Health Information Systems recently hosted a panel where clinicians and CDI professionals explored how artificial intelligence (AI) and other technology advances can improve patient care. The resulting white paper, “Elevating Clinical Documentation Integrity with Compliant Technology Adoption,” focuses on how health care systems can use technology, specifically AI-enabled computer-assisted physician documentation (CAPD), to achieve data integrity and compliance, enhance workflows, and improve value-based care models.
The benefits of CAPD are numerous. It removes some administrative burden from physicians, allowing them to spend more time with patients. With physicians spending as much or more time documenting patient encounters as treating patients, it’s no surprise many have reported experiencing burnout. “Now, AI-enabled CAPD facilitates a timelier review, delivering real-time clarification requests, or prompts, to clinicians as they document the patient encounter to help them provide an accurate and complete overview of their interaction,” the paper states.
Of course, the panelists noted that CAPD alone cannot ensure sustained physician engagement in the CDI process. The panelists said peer-to-peer education led by physicians who buy in and can serve as “champions” is especially important. This education should come as early as is feasible, and residents are an especially key group to target. “Explainability—creating an understanding of how information in the health record is used both within and outside of the organization—sheds light on CDI’s central role in enhancing quality and patient safety and achieving operational objectives,” the paper notes.
Full story » |
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AHIMA Releases New Telehealth Toolkit
AHIMA has released a new toolkit that aims to provide guidance to health care organizations about telehealth, as its use soared during the pandemic and many organizations are seeking to implement or expand their telehealth programs. The toolkit highlights the benefits of a telehealth program, including enhanced access to care and timeliness. It offers guidance to patients for telehealth appointments, recommending they test the connectivity, battery, and operation of the camera, microphone, and speakers of the device to be used; use a private and quiet space where others cannot hear the sound of the video consultation; consider wearing clothing that allows the doctor to examine them by video; and consider making a written list of concerns and inquiries prior to the appointment. The toolkit also contains an extensive overview of the definitions of telemedicine and telehealth, and features information for health care organizations considering a telehealth program, including challenges and considerations for implementing a telehealth program, both technologically and organizationally; a step-by-step guide on how to take a telehealth program from its initial stages to its implementation; and a comprehensive analysis of requirements to consider in advance of telemedicine implementation, from legal policies to documentation and reimbursement considerations. Learn more »
Partnership to Offer HIPAA Compliance Services
Compliancy Group has partnered with eMDs, a brand of CompuGroup Medical, to offer HIPAA compliance to their EHR and Practice Management Software, as well as Revenue Cycle Management Services customers. Health care providers look to their EHR vendor partner for advice on how to complete their Security Risk Analysis and ultimately how to manage HIPAA compliance more easily and effectively for their practice. Utilizing Compliancy Group’s unique Achieve, Illustrate, and Maintain methodology can improve operational efficiencies, patient satisfaction, and profitability. The Compliancy Group methodology helps practices reduce risk with a proven process to help them manage their HIPAA risk processes and take steps to secure their technology infrastructure. Compliancy Group and eMDs are focused on educating their customers with a series of webinars, educational materials, and access to the proven Compliancy Group methodology. This methodology has helped thousands of clients avoid HIPAA violations by earning Compliancy Group’s HIPAA Seal of Compliance. Learn more »
HSG Develops Strategy to Address the 2021 Medicare Physician Fee Schedule
HSG, a national health care consulting firm, has outlined a process to help health care executives and their organizations address the significant modifications made to the 2021 Medicare Physician Fee Schedule (MPFS). In addition to the Final Rule’s recognition of the increased administrative burden placed on direct care providers, the 2021 MPFS also creates an opportunity for health systems to shift their compensation philosophy and structures to be less dependent on volume and more prominently recognize value. This shift will more closely align provider incentives and payer reimbursement and promote greater long-term financial sustainability of health care organizations. The 2021 MPFS will create significant issues related to provider coding changes and eliminations, the level of wRVU credit afforded to many E/M codes, and actual Medicare reimbursement. Since the release of the MPFS Final Rule, the health care consultants at HSG have been working with hospitals and health care systems to vet the three significant variables impacting financial futures. They include coding documentation changes, compensation impact, and reimbursement projections. Learn more » |
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The Future of Prior Authorizations Is Near
Ready for the changes to electronic prior authorization? For some health care organizations, they became effective this month. Read more »
‘Reasonable and Necessary’ Gets Redefined
Don’t look now, but “reasonable and necessary” has been redefined. Read more »
Queries: Moving Beyond Business as Usual to Identify Learning Opportunities
A physician advisor who used to disdain the query process offers pointers on how clinical documentation specialists can elicit better, more prompt replies from clinicians. Read more »
Health Care’s Telehealth Conundrum
With telehealth claims increasing at unprecedented rates, providers would be wise to enlist a dose of artificial intelligence into their claim operations. Read more » |
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EHR Alerts Prove Ineffective in Reducing High-Risk Prescriptions
Researchers hoped to reduce the prescribing of high-risk medications linked to dementia in older adults, but very few of the EHR alerts were even read, according to a study by Regenstrief Institute.
Families Detail Years of Anguish as They Plead for Changes to Privacy Rule
HIPAA is often a barrier that blocks families from being involved in their loved one’s mental health care, according to Report on Patient Privacy. |
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HHS Announces Rule to Protect Consumers From Surprise Medical Bills
The Biden-Harris Administration, through the US Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management (OPM), recently issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out-of-pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and nonemergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.
“No patient should forgo care for fear of surprise billing,” says HHS Secretary Xavier Becerra. “Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs. The Biden-Harris Administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises.”
Read more » |
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