EHR - ICD10monitor

Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data.Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for more detailed data about the nature of each patient’s condition.…
In order to make healthcare effective, safe and affordable, clinical organizations must ensure complete and accurate clinical records.In preparation for my remarks on the Talk Ten Tuesdays broadcast of Oct. 31, 2017, I reviewed my own time served on this topic. I also reflected on the many people I’ve met…
Amid the chaos of the ED, order is needed.EDITOR’S NOTE: This is the final installment in a two-part series on clinical documentation integrity (CDI) in the emergency department (ED).It is my opinion that investing CDI resources into the neglected stepchild that is the hospital system ED is a worthwhile endeavor.…
A Talk Ten Tuesdays listener weighs in on woefully insufficient documentation of a routine visit.EDITOR’S NOTE: During last Tuesday’s Talk Ten Tuesdays broadcast, a listener who prefers to be called “Robert” sent an email message to us describing his recent experience as an emergency department (ED) patient – after which…
The mass shooting in Las Vegas has prompted renewed attention on emergency medicine and trauma care and especially on the clinical documentation of care in this setting. I practiced emergency medicine (EM) for twenty-five years before I transitioned to being a physician advisor. My expertise had been in the professional…
Just as we’re getting our minds wrapped around the 2,398-page Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, published by the Centers for Medicare & Medicaid Services (CMS) on Oct. 14, 2016 and becoming effective Jan. 1, 2017, a new proposed rule for 2018 was published on June 20,…
These days, when healthcare IT expert Stanley Nachimson sees a Volkswagen, he’s likely to think of the $155 million whistleblower settlement involving electronic health record (EHR) vendor eClinicalWorks (ECW) announced last week by the U.S. Department of Justice.In its announcement, the Justice Department reported that ECW, headquartered in Westborough, Mass.…
A study just out by researchers at the University of California’s San Francisco Medical Center reviewed more than 23,000 progress notes over an eight-month period and found that less than 15 percent constituted new and unique content. Residents were the worst offenders, with 88.2 percent of their text being copied…
Every two years, one of the most interesting perspectives on medicine in America is published by the Physicians Foundation via its biennial physician survey.In the 2016 survey, 17,236 physicians responded to a wide variety of questions about their practice, the state of the healthcare industry, and perspectives on specific topics,…
Two major rules published last month included major changes to the healthcare industry. First, the Centers for Medicare & Medicaid Services (CMS) issued its long-awaited Medicare Access and CHIP Reauthorization Act (MACRA) final rule on paying Medicare Part B providers for quality and performance. This new system, titled the Merit-Based Incentive…
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