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: Clinical documentation integrity (CDI), a process by which documentation is optimized to be both congruent with Centers for Medicare and Medicaid (CMS) terminology and reflect patient severity of illness, is widely used in healthcare to ensure appropriate coding for hospital reimbursement and improve accuracy of research and quality outcomes. CDI optimization is often performed [...]

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 [...]