• Home
  • clinical documentation

Posts Tagged ‘clinical documentation’

clinical documentation,Data analytics,healthcare reimbursement,Navicure,Revenue Cycle Management

Optimizing healthcare revenue cycle management in 2017

Ken Bradley, Vice President of Strategic Planning and Compliance, Navicure

If there is one thing the healthcare industry has learned in 2016, it’s that change is constant. With regards to the revenue cycle, for example, increasing patient financial responsibility coupled with pressure to improve overall revenue cycle efficiency has prompted many healthcare organizations to revisit and rethink their current operations.

As 2017 dawns, healthcare organizations are once again facing uncertainty. Although it might be tempting to wait and see how the year unfolds and then take action, this approach can lead to missed opportunities to enhance quality, reduce costs and streamline operations. In particular, the following four revenue cycle strategies warrant attention in the coming year.

1. Improve clinical documentation

Complete and precise documentation goes a long way toward preserving revenue integrity. Not only does it ensure an organization receives all the payment it deserves, it can also limit denials, smooth cash flow and lower the cost to collect. There are a variety of best practices related to clinical documentation improvement, including working one-on-one with clinical departments to boost accuracy and thoroughness. In addition, organizations can implement technology that prompts clinicians to add detail and address all required components.

Continue Reading

CDS,clinical decision support,clinical documentation,electronic medical records,Electronic Medical Records and Genomics,EMRs,interoperability,medCPU

How clinical decision support fills gaps in clinical data for higher quality care


Liora Guy-David, Ph.D., Vice President of Data, medCPU

As long as the healthcare industry lacks true interoperability among dissimilar systems, clinicians will have incomplete patient information at the point of care. This includes gaps over time, as when a clinician is unaware of imaging tests already completed, and gaps across care team members who record documentation in separate systems. Both types of gaps can compromise patient safety.

While we don’t typically think of gap-closing as being a primary clinical decision support (CDS) function, CDS systems do exactly that. Its success in informing decisions depends largely on the ability to analyze information from multiple systems, closing gaps in real-time. As a result, CDS is emerging as an essential tool for improving quality of care.

Decision-making support built with a more complete view of the patient

CDS systems run on top of EMRs, analyzing documentation as it is being entered and issuing alerts in EMR windows when conditions indicate the possibility of a medical error or compromised patient safety. This is often a matter of giving clinicians information of which they were unaware.

To fully inform alerts, advanced CDS systems supplement the structured data in EMRs and pull information retrieved from other systems such as those in labs and imaging departments. CDS leverages its comprehensive patient view by applying rules-based analysis regarding diagnoses and courses of care. By augmenting a physicians’ expertise with real-time information retrieval and gap-closing, CDS systems play a key role in promoting patient safety.

Continue Reading

clinical documentation,clinical documentation improvement,EHR,electronic health record,Jacobus Consulting

Comprehensive clinical documentation done right


Paulette Schroeder, Senior Managing Director of Clinical Informatics, Jacobus Consulting

Riddle me this: “If a tree falls in a forest and no one is around to hear it, does it make a sound?”

Riddle me that: “If a clinician provides exemplary care to a patient but doesn’t document it properly, is it considered quality care?” While the latter isn’t a riddle, health systems and care providers have focused less on optimizing electronic documentation practices. An effort to provide exemplary care is likely to go unnoticed under emerging regulatory and value-based care models if it isn’t documented appropriately. As providers are increasingly being reimbursed based on the quality of care delivered – as opposed to merely the quantity of care provided – accurate documentation is more important than ever before. Therefore, provider organizations need to lay the groundwork for optimal documentation sooner rather than later.

Clinical information collected as part of the electronic health record (EHR) is becoming a critical component of documentation as organizations seek to improve the health of patients and populations under these emerging models. Clinicians are being called upon to meticulously document that high quality care services are, in fact, being delivered. Such documentation can, in turn, feed the constantly evolving knowledge base of best practices.

Factoring for comprehensive clinical documentation: Healthcare provider organizations need to look at current clinical documentation practices, identify gaps and make the changes that will lead to enhanced quality and subsequently improved reimbursement. To get started, here are 10 important factors that provider organizations should consider as they strive to create the comprehensive clinical documentation programs that will lead to success under value-based care:

Continue Reading

athenahealth,clinical documentation,cloud-based EMR,Nuance,Nuance Dragon Medical 360

Nuance joins athenahealth’s “More Disruption Please” Marketplace

Nuance Communications, announced it has joined athenahealth’s “More Disruption Please”(MDP) program, making Nuance Dragon Medical 360 part of the athenahealth Marketplace offerings to more readily connect clinicians to the tools they need for a seamless documentation experience. This collaboration enhances the efficiency of clinicians as they use voice recognition to document care and navigate electronic medical records (EMR) in the fast-paced ambulatory setting where more than 30 percent of patients spend 10 minutes or less with physicians.

According to the U.S. Census Bureau’s latest analysis published November 2014, ambulatory healthcare services rose nearly 24 percent over a five-year period, and physicians’ offices accounted for nearly half of all ambulatory care services. In 2014 alone, use of Dragon Medical Clinic 360 | Transcription, Nuance’s solution for the ambulatory clinic market, doubled in overall volume as a tool used for capturing clinical documentation. Today, more than half of U.S. clinicians use Nuance Dragon Medical 360 solutions to document care faster using technology that enables them to tell the whole patient story while getting the structured data the industry needs.

“We are excited to partner with Nuance, an industry-leading dictation solution with the goal of saving time and increasing efficiencies for our providers,” said Kyle Armbrester, chief product officer at athenahealth. “The integrated Nuance solution aims to address the many pain points of EMR documentation by seamlessly integrating speech recognition into the workflow – in real-time and on any device.”

“Clinicians want advanced speech solutions that enable them to tell the complete patient story in their own words through streamlined clinical documentation. The inclusion of Nuance Dragon Medical solutions in the athenahealth Marketplace provides thousands of clinicians with a choice of using front-end speech recognition or dictation to easily create patient records directly in athenahealth’s cloud-based EMR,” said Susan Sumner, vice president of ambulatory solutions, Nuance Communications. “This collaboration promotes physician productivity and documentation quality while supporting patient-centric care.”

Continue Reading

clinical documentation,electronic medical record,EMR,M*Modal,patient outcomes,Preferred Solutions,Speech Understanding,The Preferred Approach

M*Modal and Preferred Solutions partner to provide hospitals with adoption services for speech-based clinical documentation platform

M*Modal, a provider of clinical documentation and Speech Understanding solutions, and Preferred Solutions, a healthcare IT consulting, staffing, and training firm announced a partnership for increasing physician adoption of electronic medical record (EMR) systems. The companies will offer onsite training at hospitals for using M*Modal’s front-end speech technology platform to improve clinical documentation quality and patient outcomes.

Preferred Solutions will provide training and adoption services for M*Modal’s Fluency Direct software, which enables doctors to conversationally create and edit clinical data directly within existing EMR systems. The partnership leverages each company’s capabilities to provide healthcare organizations with the technology and skills needed to streamline physician workflows, increase productivity and enhance clinical documentation improvement (CDI) programs.

In addition to Fluency Direct, physicians will receive training on M*Modal’s computer-assisted physician documentation (CAPD) module, which provides real-time feedback to physicians on common documentation deficiencies to help eliminate costly and time-consuming queries later in the care cycle.

“Physicians need to work at their best, and this collaboration is about teaching them better ways to document, to be more efficient and productive,” said Scott MacKenzie, CEO of M*Modal. “The combination of M*Modal’s flexible, clinical documentation platform with Preferred Solutions adoption services supports hospitals in their documentation improvement programs  and getting the most out of their electronic medical record systems.”

Continue Reading

Allscripts,Cerner,clinical documentation,CPSI,EHR,Epic,Fluency Direct,HIMSS 2015,KLAS,M*Modal,McKesson,Meditech

M*Modal enhances fluency direct front-end speech solution for physicians

M*Modal, a provider of clinical documentation and Speech Understanding solutions, announced enhancements to its Fluency Direct front-end speech software. Improvements in system customization, platform integration, speech understanding and software management can help physicians and healthcare professionals more quickly and easily create high-quality clinical documentation in electronic health record (EHR) systems.

M*Modal will be demonstrating Fluency Direct at the 2015 HIMSS conference at booth #2243.

Fluency Direct is cloud-based software that allows healthcare providers to verbally create and edit patient narratives directly in EHR templates. The solution leverages M*Modal’s Speech Understanding and Natural Language Understanding technologies to combine highly accurate speech recognition with embedded clinical documentation improvement (CDI) capabilities.

Continue Reading

clinical documentation,dictation,Dragon Medical 360,EHR,HIMSS 2015,mobile app,Nuance,PowerMic Mobile,Samsung,workflow

Nuance to showcase new clinical documentation tools for mobile devices and wearables

Nuance Communications announced that it will showcase its newest innovations for bringing clinical documentation to smart devices, smart watches and the Internet of Things at the 2015 Health Information Management Systems Society (HIMSS) Annual Conference.

In conjunction with this year’s event, Nuance has announced PowerMic Mobile, which will be available in May 2015. This new mobile app can turn any iOS or Android mobile phone into a powerful and secure dictation device that allows physicians to easily dictate, edit, and navigate within the EHR simply by speaking. The app also provides physicians with flexibility in how and when they dictate information into patient records supporting a more convenient workflow.

In addition, recognizing the strong interest in smart watches and other personal devices, Nuance has teamed with Samsung to develop a use case for PowerMic Mobile that will allow physicians to dictate directly into an EHR using Dragon Medical 360 and the Samsung Gear S smart watch. Nuance and Samsung will showcase this innovation in their HIMSS booths, numbers 1831 and 7523, respectively.

“2015 has turned into the Year for the Internet of Things and the phenomenon is becoming firmly entrenched in healthcare,” said Jonathon Dreyer, Director of Cloud and Mobile Solutions, Nuance Communications. “We are very excited to leverage our deep experience in this domain and to work with a pioneer such as Samsung to bring the power of voice to a new class of documentation tools that bridge conveniences found in clinicians’ personal lives to the healthcare environment.”

“Samsung is a pioneer in smart watches that are not just functional but stylish,” said Ted Brodheim, Vice President of Vertical Business at Samsung Electronics America. “Our Gear S like its predecessor smart watches, keeps health and fitness monitoring as a key feature, so this extension of Gear S to improve the healthcare experience is a natural partnership.”

Continue Reading

Get our eNewsletter

Email Marketing powered by StreamSend

Please follow & like us :)

Follow by Email
©2018 HIT Leaders and News LLC. All rights reserved.