Electronic Clinical Documentation Report

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

EPIC EpicCare is rated as the best Acute care and Ambulatory EMR for large hospitals with more than 75 physicians (KLAS Research,2017). As Houston Methodist (HM) is committed to Leading medicine and improve patient experience, the leadership decided in 2013 to shift from MethOD an EMR based on Allscripts® to a new EHR looking for an integrated solution that will help build a complete and robust patient story, easily accessible by the care team to help them make more informed decisions in order to achieve better health outcomes, improve communications, and get patients more involved by providing them with convenient online tools. HM started the vendor selection process in 2014 and in 2015 they decided to go for EPIC EpicCare

information is loaded into the individual’s medical record to provide an ongoing record of the

Clinical documentation Improvement (CDI) is the program or the training that is design to provide the good link between coders and health care providers that increase the accuracy and completeness of patient health care documentation. According to American Health Information Management Association (AHIMA) tool kit CDI is the program especially design for health care field for initiate concurrent and, as appropriate, retrospective review of patient health records for accurate, incomplete, or nonspecific provider documentation (Scharffenberger and Kuehn 2011). Most of the time patient health record review occur in inpatient location but it there is any confusion then the review can go through electronic health records too. CDI play a vital role solving complex case between coder and health care provider that result in easy and smooth operation of reimbursement process in health care organization for the service they provide to patient.

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

In early 2011 Children’s Hospital of Wisconsin (CHW) informed it patients and the general public that it would be fully immersed in another version of the electronic health record system, EPIC, by the completion of the 2012-2013 fiscal year. With so many hospital, clinic, and community locations, the hospital needed to implement the system in phases and fully engage thousands of

Our one hundred bed hospital is in need of updating from paper charting to computerized health records. In doing this, we will meet our goal of compliance with meaningful use legislation. We assembled a team of members to assist with this task and together we have narrowed the search to two health care systems. Those two systems are EPIC and Meditech and we will now discuss the advantages and disadvantages of each, with a final recommendation for our new healthcare system.

Epic resulted in the transformation of Yale-New Haven Health by substituting disparate EHR’s (electronic health records) and the health system with a centralized EMR (electronic medical record) and a revenue cycle platform. Lisa Stump revealed that Yale-New Haven Health applied a Big Bang approach to ensure uniformity of implementation for the Epic system. However, she maintains that there was need to modify the approach based on the requirements of the existing practice. Again, the Vice President added that effectively achieving uniformity in Epic’s implementation was more about managing the resultant change and thinking actively on the ways of managing the change for Yale-New Haven Health. The task of implementing Epic at Yale-New Heaven Health incorporated the participation of its nurses, employees, and doctors. Moreover, redundant modifications were removed in Epic’s implementation because the organization is dedicated to ensuring standardized content and workflows. The benefit of applying the Big Bang approach in ensuring uniformity is that an entire hospital goes live on an EMR with a periodical departmental roll-out strategy. Consequently, the approach helps in ensuring that each person is

I’m glad to hear that your hospital is getting the Epic network. We have had both negative and positive experiences with the Epic system. Much of the frustration had to do with the way applications were set up and needing time to learn new system. On the hand, electronic documentation has enhanced communication between clinicians including nurses. Also, electronic documentation reduces medical errors and improves patient care. Although electronic documentation has improved nurse’s communication and efficeincy, it brought new terminologies that are specific to electronic documentation. These terminologies are standardized and require nurses to learn and use accurately (Sewell, 2016).

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

My facility has rolled out the implementation of Epic electronic health system. The implementation process started at the primary acute hospital setting, beginning on a test unit. It was then rolled out to the other hospital locations. All health care providers were mandated to

I spoke with the Director of Informatics, Dorothy Vanderweil, to learn how our hospital addressed the implementation of an EHR. Dorothy was able to tell me how they assessed readiness, planned their approach, selected a certified EHR, and conducted training and implementation of the EHR. HMC assessed the specific flow of each department. At the start, they discovered there were individual needs for each department. They then assessed which departments could consolidate to share work flow. They evaluated the need for training of individuals and found many staff could barely use a mouse. HMC determined which devices would best suited when documenting in the EHR, along with how many devices were needed. The planning then began and the decision was made to use the C5 tablet for documenting. Of course, they needed to know the cost involved with the procurement of these devices. Decisions were made as to how and what they wanted to be able to view and chart. Since they were moving from paper charting there was no data integration to be concerned about. They formulated a plan for training including the adoption of super users for extra support during the first few months of going live. They selected Cerner as the EHR system to implement. Once all staff were trained and physicians as well, a decision was made to go live. By January 2010 HMC was ready and implemented the EHR certified system Cerner. Go live was very well planned with extra staff

The connections between auditing, accurate diagnostic and practical coding with CDI programs is that the clinical documentation improvement (CDI) is that revising and monitoring offers oversight for the CDI program, understanding into physician documentation and collaboration, and objective assessment of the performance and efficiency of individual CDI staff members as measured against the facility’s policies and

Speaking of charting and changes in health care, I think Electronic Medical Records(EMR) has changed the entire health care world. The way of charting by paper is long gone and computerized records has taken over. I remember back in the day, 1989, nurses would complain about having to write so many notes. I have to chuckle as I am writing this, I can remember checking all my patients in the beginning of my shift, and then I would sit down with up to 15 charts piled up next to me, and I would start my charting. Back then, we could do a task and then chart it when we had the chance, which could be the end of the shift. Now, we have to chart as we care for the patient. I guess you can back chart, but then the time is noted as to when you charted

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).