Health Information Management

News: Report cites lack of detailed physician documentation as challenge to effective electronic health record initiatives

CDI Strategies, September 2, 2010

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As facilities vie for government incentives to implement electronic health record systems they may find CDI programs provide a hidden benefit.

The biggest challenge related to meeting governmental standards for “meaningful use” of EHR “is that they require physician documentation and electronic medication administration, not just in the hospital but also in the ED,” according to an August report from the CSC Healthcare Group.
 
When the final rule regarding requirements for “meaningful use” was released in July, it included 15 clinical quality measures hospitals must electronically report by 2012. If facilities only meet the basic requirements for so-called Stage 1 EHR they capture a mere 35% of the total data required…, the CSC paper states. The rest of the required information typically comes in narrative form in physician documentation, and many EHRs do not have physician notes sections.
 
CDI administrators may wish to offer their insight regarding physician documentation as their facilities begin to explore EHR options and seek out vendors.



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