Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we […]

Background: Accurate documentation of the patient’s diagnoses helps to reflect the severity of illness which has several downstream impacts: clinical outcomes data, risk stratification, hospital quality metrics data such as readmission and mortality index, hospital reimbursement. For this reason, our health system has various ongoing initiatives on clinical documentation to improve the specification of certain […]

Background: Time spent on electronic medical record (EMR) documentation is one of the top dissatisfiers for providers. With burnout at an all-time high, reducing provider burden while maintaining high quality care is essential to moving healthcare forward in a sustainable way. “While electronic documentation provides a number of benefits as compared to paper-based documentation, including […]

Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we […]