Changes in Clinical Documentation

While at AHIMA 2012, I had a chance to sit down with Dr. Jon Elion, Founder and CEO of ChartWise Medical Systems. I asked him about the changes in clinical documentation he’s seeing and I grabbed a video of his answer below. His answer was an interesting and insightful look into clinical documentation and ways that coding is effecting the clinical documentation.

I find Dr. Elion’s answer quite interesting in the terms of using clinical documentation intelligence in EHR. Add in things like coding engines, NLP, and EMR templates and you can see why getting the documentation right is a challenge even in an IT optimized world.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

2 Comments

  • Great video stressing some important issues. I could not agree more with the need to have more real data originating from the point of care.

    1. With the impending physician shortage, is it wise to add 5-9 minutes of extra physician work to each patient encounter (i.e. 2-3 hours of homework) each day via forcing them to be the ones filling in structured templates?

    2. Is there risk in allowing use of these but saving time by utilizing documentation by exception?

    3. If a physician has to edit both the raw dictation and the NLP outputs, does this add any real efficiencies?

    4. How does speech recognition with NLP ensure that consistent data points are collected consistently?

    5. Is there any evidence that these approaches will be sustainable as fees for services continue to fall?

    Just asking.

  • I agree to Dr. Oates. Have given birth to a medical practice and manage it actively for 13 years. I have financial credentials and a good indepth experience in the financial sector before I took over this practice.

    No one complains about the short cuts that wall street uses in their charting and displaying on all news channels about which stock (usually a code name is used) did and the margins involved. So If as the speaker says the Doctors have to then unravel their short names back to basics then efficiences are lost. Rather have a standardized format that is used in other industries financials, chemical, electrical and make it mandatory that all other vendors and related parties like billing and coding industries understand the correct usuage. Are they not getting paid for their specific services. Then once these short names are standardized they need to understand them and bill accordingly. It is not the job of the doctor to break conditions back to basic english language.
    I feel so sorry for the medical community that is being hit on all sides with drastic cuts in reimbursements and still being called the villians of patient care. For example everyone makes a big fuss about chart cloning. Cloning is nothing but an extension of chart templating…which is where the EMR technology is right now. The government forcing the medical community to buy this technology with penalizing 1 to 2% cuts of further all reduced reimbursements and then later performing “chart audits” for cloning is unethical.
    The government should go after the vendor communities who are responsible to providing cloning technology. Do not cut the hand that heals and let me repeat silently and bears the brunt of everyone else’s anger. These docs do bear their Hippo oath well.

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