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E-Newsletter • March 2024 |
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Editor's E-Note
Clinical documentation integrity is challenging, but new technology is making easier. Learn how artificial intelligence is enhancing documentation and, thus, improving clinical care.
In addition to reading our e-newsletter, be sure to visit For The Record’s website at www.fortherecordmag.com. We welcome your feedback at edit@gvpub.com. Follow For The Record on Facebook and X, formerly known as Twitter, too.
— Kate Jackson, editor |
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The Evolution of Clinical Documentation
By Keith Loria
Over the past decade, clinical documentation has experienced some meaningful shifts with the advancement of EHRs and artificial intelligence (AI) tools.
“Today, EHRs help capture over 30,000 data points per hospital visit and generative AI is starting to increase that even more,” says Michael Gao, MD, CEO and cofounder of SmarterDx. “To better sort all of this data, clinical documentation has evolved from an individual effort to complex CDI [clinical documentation integrity] teams and processes with multiple roles—auditors, educators, second-level reviewers—and technology and vendor support.”
With these tens of thousands of data points, hospitals now have a more complete picture of the patient journey than ever before.
However, Gao notes, sometimes that picture is more like a jigsaw puzzle.
“All of the pieces are there, but they’re not necessarily assembled in the right order to tell the full, accurate story,” he says. “Templates, structured documentation tools, defined rules, and AI can help process this avalanche of data for CDI teams, so they can make more informed decisions that positively impact patient and financial health.”
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IT Worker Layoffs
Becker’s Health IT reports on the recent increase in IT staff layoffs at health systems and the potential repercussions.
Closing Equity Gaps
Healthcare IT News talks with Alexandra Hunter, a virtual care consultant at Henry Ford Health in Detroit, about how health systems are addressing and closing equity gaps—the subject of her recent presentation at HIMSS.
How to Ask Your IT Vendors for More
Rashaad Bajwa, CEO of Integris, a premium IT-managed service provider, argues in a Forbes article that asking for more is the key to maximizing return on IT consulting expenditures.
Reducing High-Risk Drug Combinations With a CDS System
The findings of a multicenter study led by Amsterdam University Medical Center and conducted in ICUs in Holland indicates that a computerized decision support system tailored to the ICU environment improves safety and patient monitoring. |
| Have a coding or documentation question? Get an expert answer by sending an email to edit@gvpub.com. |
Coding Reference Guides
IR/CV medical coding reference guides by ZHealth Publishing are now being offered by Libman Education as a workplace resource and supplement to ZHealth webinars and courses, also offered by Libman Education. Topics include interventional radiology, diagnostic and interventional cardiovascular coding, vascular and endovascular surgery coding, cardiothoracic surgery coding, diagnostic radiology coding, pain management coding, and ICD-10-PCS Coding Companion for Interventional Radiology. Learn more about ZHealth Publishing and Libman Education.
Cloud-Based Data Management
NewOrg is a secure cloud-based data management system for nonprofit, social services, or governmental public sector organizations. Learn more »
AI-Powered Coding and Revenue Cycle Workforce Automation
Aidéo Technologies, a provider of AI-powered medical coding workflow productivity tools, and MedEvolve, a provider of data-driven solutions that provide effective intelligence, automation, and accountability for health care organizations, have announced a partnership to integrate Aidéo’s Gemini Coder Platform and Gemini AutoCode solutions with MedEvolve’s award-winning Effective Intelligence suite of solutions. Learn more about Aidéo Technologies and MedEvolve. |
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