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EMR Add-Ons On The Way

Posted on March 3, 2017 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

A new study backed by speech recognition software vendor Nuance Communications has concluded that many healthcare leaders are planning to add new technologies to supplement their EMRs, Popular add-ons cited by the study include (naturally) speech recognition, mobility options and computer-assisted physician documentation tools. While the results are partially a pitch for Nuance, of course, they also highlight the tension between spending on clinical improvement and satisfaction and boosting the bottom line with better documentation tech.

The study, which was conducted by HIMSS Analytics, was designed to look at ways to optimize EMRs and opportunities to improve care at hospitals and health systems. Conducted between August 17 and September 6 of last year, it draws on 167 respondents from 142 different healthcare organizations. Forty percent of respondents hold C-suite titles, and an additional 40% were in IT leadership. (It would be interesting to see how the two groups’ perceptions vary, but the study summary doesn’t provide that information.)

According to HIMSS, 83% of respondents reported having confidence that their organization would eventually realize their full potential, particularly improving care coordination and outcomes.

To this end, 75% of respondents said they’d boosted their EMR efforts with training and support resources, while two-thirds have increased staff in at least one IT area since implementing their system. Respondents apparently didn’t say how much they’d increased their budget, if at all, to meet these needs – and you have to wonder how these organizations are paying for these efforts, and how much. But the report didn’t provide such information.

To increase clinician satisfaction with EMR use, 82% of respondents said providing clinician training and education, 75% are enhancing existing technology and tools and 68% adopting new technology and tools. To read between the lines once again, it’s worth noting that hospitals and health systems seem to be putting a stronger emphasis on training than new tech, which somewhat contradicts the study’s conclusions. Still, EMR add-ons clearly matter.

Meanwhile, about one-quarter of survey respondents said that they planned to introduce EMR-enhancing tools at the point of care, primarily to improve documentation and boost physician satisfaction. Those included mobility tools (44%), computer-assisted physician documentation (38%) and speech recognition (25%). These numbers seem a bit lower than I would have expected, particularly the mobile stat. I’m betting that establishing mobile security is still a tough nut to crack for most.

While increasing clinician satisfaction and improving care outcomes is important, boosting financial performance clearly matters too, and respondents said that improving documentation was central to doing so. Fifty-four percent said that better documentation would reduce the number of denied claims they face, 52% expect to improve performance under bundled payments, 38% predicted reduced readmissions and 38% thought documentation improvements would better physician time management and improve patient flow.

Again, I doubt that C-suite execs and IT leaders will pay equal attention to tools which improve their finances and those which meet “softer” goals – and financial goals have to take priority. But these stats do suggest that hospitals and health systems are giving EMR add-ons some attention. It will be interesting to see if they’re willing to invest in EMR enhancements — rather than burrowing deeper into their existing EMR tech — over the next year or two.

Will Medical Coders Be Needed in the Future? – HIM Scene

Posted on October 26, 2016 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the HIM Series of blog posts. If you’d like to receive future HIM posts in your inbox, you can subscribe to future HIM Scene posts here.

After spending time with so many HIM professionals at the AHIMA Annual conference, I’ve come back thinking about the future of medical coders. No doubt, many HIM professionals are moving well beyond medical coding into other areas such as healthcare analytics, clinical documentation improvement (CDI), EHR optimization, and much more. However, there’s still a massive need for high quality medical coding and the HIM professionals that provide that service.

As we look into the future, the techie in me feels like medical coding should be automated. Why are we paying people to do medical coding? Why can’t that be automated and be done by robots? It’s not like medical coding is a particularly fun job. I’m sure there are some times it’s fun working on unique cases, but it can be quite monotonous and tedious. Why not have a computer do it instead?

What I’ve learned over the years is that medical coding is more art than it is science. Certainly there are some clear cut cases where it’s basically science. However, a large part of what a coder does isn’t set in stone. There’s some artistic licence if you will, or at least some interpretation that has to happen in order to code a visit properly. Computers aren’t good at interpretation, but humans are.

The other reality is that doctors don’t produce perfect documentation. If they did, then we probably could code a robot to code a patient visit. Since there are nuances to every physician’s documentation, we’re going to need humans that interpret those nuances as part of the coding process. I don’t see this changing in our lifetimes.

One word of caution. Many people fall into the trap that we need automated robot coding to be perfect for it to accepted. That’s just not the case, because human coders aren’t perfect either. In fact, there’s some research that human coders aren’t as good as we thought they were at coding, but I digress. The reality is that automated coding just has to be better than humans, it doesn’t have to be perfect. Even with this said, I don’t see it happening for a while.

What we do see happening now is a collaboration between humans and computers: computer assisted coding. While we don’t have to worry about computers replacing humans in medical coding, we do need to focus on ways that technology can make the work humans do better. That’s a powerful concept that we’re starting to see happen already.

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Ensuring Quality Throughout the Evolution of Clinical Documentation

Posted on October 14, 2015 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.

When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.

Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.

Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.

Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.

Is There Such a Thing As Stand-Alone Clinical Documentation?

Posted on September 23, 2015 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Imagine if every interested party in healthcare relied on one black and white document to determine a patient’s health care needs, insurance coverage, quality ratings and accreditation, or medical necessity for hospital admissions. This document would have to contain a large amount of information and it would probably end up being very cluttered. Our practices today require creating  an “abstract” of the record consisting of multiple documents and data sources or sometimes requestors want an entire record sent to them which could be hundreds or thousands of pages.

Until we get to the point of easily sharing interoperable data electronically through HIEs, we will continue to rely on release of information practices of fulfilling requests for records by pulling pertinent information from the chart. We find ourselves asking daily, “what is the minimum information we can send that will provide the most information?” We joke about how EHRs have actually increased the amount of paper used to print a chart because of formatting and “note bloat” from trying to cram too many things into each document. Could we ever get to the point of having just one patient summary document that can be shared across providers and levels of care?

I don’t think patient data and information can be summarized into one document in a chart nor should it be. If that were the case, medical records would consist of one source-document instead of the dozens of tabs and modules we have in the EHRs today. Due to the fact that opening up an entire chart to every authorized reviewer is not currently secure or feasible, we are still looking for information sharing solutions involving summarized documentation. That being said, the chart should have key data elements pointed to a destination document where the patient’s course of care would be summarized neatly in one place to prevent the author of the note from having to re-state information repeatedly. I do see some movement toward the single, stand alone document trend but I think there is still quite a bit of work to be done.

The continuity of care document (CCD) was created with the objective of standardizing a single document that could be sent to the next care provider. This document may also be referred to as the After Visit Summary or Discharge Instructions but CCD was coined by HL7 for Meaningful Use electronic exchange initiatives. This template intends to capture important elements from a patient’s clinical data including the problem list, history, vitals, and more pertinent information that would be helpful to the patient’s next provider.

So why does The Joint Commission (TJC) still require so many other documents in the chart if we are able to summarize the care well enough for the next provider with one document? With the focus of health IT professionals being on Meaningful Use and EHR optimization, I see a divide in objectives across departments within healthcare organizations because we are trying to please many different accrediting bodies or payers. I don’t believe there will be a time in the near future when everyone agrees on a standardized record set therefore documentation will continue to evolve with each requirement that comes along. In the meantime, we must ensure the minimum necessary information is shared for continuity of care in a concise and effective manner.

If you’d like to receive future HIM posts by Erin in your inbox, you can subscribe to future HIM Scene posts here.