The Winter 2019 issue of Perspectives in Health Information Management features a review of the expanding for of clinical documentation, a study of EHR documentation times, and a literature review of quality of life surveys to determine the correct approach to trauma-affected communities.
Physicians spend a large portion of their time documenting patient encounters using electronic health records (EHRs). Meaningful Use guidelines have made EHR systems widespread, but they have not been shown to save time. This study compared the time required to complete an emergency department note in two different EHR systems for three separate video-recorded standardized simulated patient encounters.
Emergency care is usually conducted within limited time and with limited resources. During emergency care processes, data quality issues should be taken into account. The aim of this study was to assess the quality of emergency care data from the perspectives of different data stakeholders. This survey study was conducted in 2017. In this research, the viewpoints of three groups of data stakeholders, including data producers, data collectors, and data consumers, were collected regarding data quality in emergency care services. Data were collected by using a standard information quality assessment questionnaire.
The future of clinical documentation improvement (CDI) will require expanding the reach of CDI programs into new areas of expertise because the traditional realms of CDI work are increasingly becoming automated. CDI-based research and analytics can serve as a means for demonstrating continued value to an institution. We present four studies as examples of these efforts.
