Tag Archives: EHR

Analyze this! Administrative claims data or EHR data in health services research?

One of the ongoing debates in health services research concerns the relative merits of using administrative claims data versus electronic health record (EHR) data for research. Should one be preferred over the other? Some question the degree to which administrative claims data continue to be valuable for health services research given the growth of EHR systems. Continue reading

Copy-paste in the EHR

Should physicians use the “copy-paste” function to document in the EHR?  In his latest blog post, 3M HIS blogger Jeremy Zasowski uses a whiteboard to sketch out the pros and cons, and offers two case studies that get to the heart of the copy-paste issue.

Watch the video here.

Copy-paste in the EHR title screen

 

Continue reading

HIMagine That! Queries for ICD-10

Donna: You know Sue, I think that people are really stepping up their ICD-10 game as we enter the home stretch.

Sue: The way I look at it, they’ve been stepping up their game for the last five years!

Donna: So true. Still, I’ve received a lot of emails lately from coding and CDI professional requesting assistance with ICD-10 queries that they can use to ensure they have ICD-10 ready documentation.

Sue: So what kinds of queries are they asking about? Continue reading

Physicians and Coders: No More Unspecified Care

The team I work with has done an enormous amount of work translating medical necessity policies from ICD-9 to ICD-10. And we have had many discussions regarding the codes that represent “unspecified” care in ICD-10. Should they stay in the translations – or go? Is ICD-10 specific enough to cover all care and coding contingencies now?

Unspecified Defined

An internet search (don’t you love being able to search so easily?) revealed:

Un-spec-i-fied: (adjective) meaning “not stated clearly or exactly”. Synonyms: unnamed, unstated, unidentified, undesignated, undefined, unfixed, undecided, undetermined, uncertain… Continue reading

Better Living—and Documentation—Through Computer Assistance

Have you ever driven a car without power-steering? It’s quite a workout. We used to all drive without power-steering and for “entertainment” you had to spend ten minutes twisting a small dial back-and-forth trying to get a radio station to come in clearly, only to drive under a bridge and completely lose it. Now we’re on the verge of self-driving cars and I can stream an entire album saved in the cloud into my car just about anywhere and anytime I want. No more fine-tuning that pesky radio dial. Continue reading

My Wish List for HIMSS15: Bring Documentation into the Health IT Conversation

For the past two years, I have been fortunate to attend the HIMSS Annual Conference & Exhibition in both New Orleans and Orlando. HIMSS puts on a massive event for about 38,000 people, so it’s definitely a great place to learn and network around the newest technologies, trends, and solutions in healthcare information technology. HIMSS15 kicks off in Chicago on April 12, and although I am unable to attend this year, I’ve been thinking about the conversations and ideas I hope will be generated by the organizers, presenters and attendees. Continue reading

Partial Dictation: A Smart Compromise for Quality Documentation

Last month, AHDI created a new Facebook group called “SR Errors – Funny or Fatal?” as a forum for healthcare documentation specialists (HDS) to share speech recognition “bloopers” that they caught during the editing process.

The submissions vary from hilarious:
“The patient slipped on the ice and fell on her Botox.”

To scary:
Dictated: “Lipitor 20, two pills a day”
Speech recognition result: “Lipitor 22 pills a day” Continue reading

Airbags and Analytics

I am not a fan of cold weather. Not a snow lover, don’t like sleet, detest freezing rain and ice and the resulting traffic accidents. Most folks don’t think about their airbags until they begin to skid on an ice-covered road and suddenly it becomes one of the most critical components of the vehicle.

Bad weather makes me think about the news reports of the frightening problems with faulty airbags. I was surprised to hear reports that the problem impacts the entire price range of vehicles – from economy to luxury brands. The news got me thinking – is an airbag a component auto manufacturers would compromise? Continue reading

The Oops Factor: Are Documentation Edits Nitpicky or Necessary?

In my last two “Oops Factor” posts, I discussed the necessity of addressing critical errors in healthcare documentation that could affect patient safety, as well as non-critical errors which may not harm the patient, but could impede the reader’s understanding of the content. But what about the nitpicky stuff? How far should editing go in the electronic world in which we now work?

I remember when I started consulting with hospital transcription departments almost 20 years ago that it mattered very much how the document appeared on paper and that every detail of spelling, grammar, punctuation, and other stylistic rules were maintained. Nowadays, adoption of speech recognition and direct EHR entry have fostered a new mindset of getting the documentation created as quickly as possible without worrying about minor issues. The advent of this mindset is in direct correlation to the expectation that the new technologies are efficient enough that physicians and other clinicians should create their own documentation without assistance. Continue reading

Resolution 2015: Time to Audit

Like many, the end of the year is a time of reflection and planning for me. Where did I succeed in 2014 and where do I need to focus in 2015?

One of my plans for 2015 is cleaning the basement. I know, I hate doing it too – that’s why I had to make it a resolution – give it more emotional power.

My daughter graduated from college in 2006 and wanted to “leave some of my stuff here temporarily.” It’s now 2015 and that stuff is still in my basement. Does she need it? Likely not, since it hasn’t seen the light of day in nine years. But before it’s moved, we’re going to go through it and throw out what’s no longer needed. I’ve learned that it makes more sense both from a time and cost perspective, to clean up before a move than to pack, move, unpack and then throw out the same stuff. Continue reading