Clinical documentation
Electronic health record systems standardize clinical documentation so health IT tools can automate data entry and facilitate information exchange across healthcare systems. See how these technologies improve the accuracy, completeness and timeliness of clinical documentation.
Top Stories
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Feature
01 Mar 2024
3 EHR training best practices for clinician satisfaction
By providing specialty-specific EHR training, using e-learning modules, and encouraging ongoing EHR education, healthcare organizations can help promote clinician satisfaction. Continue Reading
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News
25 Oct 2023
CalHHS Names 9 Qualified Health Information Organizations for DxF
The designation of qualified health information organizations is a major step forward in implementing the CalHHS health data exchange framework (DxF). Continue Reading
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Definition
08 Feb 2024
clinical decision support system (CDSS)
A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care. Continue Reading
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Definition
05 Feb 2024
personal health record (PHR)
A personal health record (PHR) is an electronic summary of health information that a patient maintains control of themselves, as opposed to their healthcare provider. Continue Reading
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News
25 Oct 2023
CalHHS Names 9 Qualified Health Information Organizations for DxF
The designation of qualified health information organizations is a major step forward in implementing the CalHHS health data exchange framework (DxF). Continue Reading
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News
05 Oct 2023
University Hospitals Transitions to Epic EHR to Drive Care Coordination
The health system converted over 5.6 million patient records to an Epic EHR system to enhance care coordination and streamline patient scheduling. Continue Reading
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02 Oct 2023
Understanding Cloud-Based EHR Platforms and Their Benefits
As the digital health transformation progresses, cloud-based EHR platforms could hold the key to health IT scalability for provider organizations. Continue Reading
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29 Sep 2023
Are Medical Specialty Societies Key to Advancing Health Data Standards?
Medical specialty societies are well-suited to drive consensus on health data standards, as they include a diverse sampling of representatives from the field. Continue Reading
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Feature
25 Sep 2023
How a Behavioral Health Center Uses HIE to Drive Patient-Centered Care
Connecting to an HIE has helped a behavioral health center in Connecticut drive patient-centered care through real-time alerts and streamlined data access. Continue Reading
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Feature
14 Sep 2023
What Are the Four Levels of Health Data Interoperability?
According to the Healthcare Information and Management Systems Society (HIMSS), health data interoperability has four levels: foundational, structural, semantic, and organizational. Continue Reading
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07 Sep 2023
How Will Information Blocking Enforcement Drive Interoperability?
Enforcement of the ONC interoperability rule has begun, with civil monetary penalties of up to $1 million per information blocking violation. Continue Reading
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Feature
23 Aug 2023
How HIE Tools Can Bridge the SDOH Data Interoperability Gap
Across the nation, HIE networks are advancing SDOH data interoperability with community-based organizations to support value-based care. Continue Reading
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Definition
09 Aug 2023
Continuity of Care Document (CCD)
A Continuity of Care Document (CCD) is an electronic, patient-specific document detailing a patient's medical history. Continue Reading
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News
21 Jul 2023
Care Org Targets Enhanced Patient Care with Oracle EHR Implementation
An Oracle EHR implementation is set to streamline integration between physical and behavioral healthcare, paving the way for better patient care decisions. Continue Reading
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Definition
21 Jul 2023
Continuity of Care Record (CCR)
The Continuity of Care Record, or CCR, provides a standardized way to create electronic snapshots about a patient's health information. Continue Reading
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Definition
20 Jul 2023
legal health record (LHR)
A legal health record (LHR) refers to documentation about a patient's personal health information that is created by a healthcare organization or provider. Continue Reading
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News
14 Jul 2023
CommonWell Health Alliance Reaches Network Population Milestone
The trade association has surpassed a nationwide health data network population of 200 million individuals. Continue Reading
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News
06 Jul 2023
Epic EHR Set to Streamline Care Team Communication at Albany Med
The Epic EHR will provide Albany Med clinicians with a secure chat function and mobile platform to support care team communication. Continue Reading
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News
27 Jun 2023
Epic Announces Ambient Clinical Documentation EHR Integration
The ambient clinical documentation EHR integration is set to enhance Epic workflows by automatically drafting EHR notes. Continue Reading
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Feature
20 Jun 2023
How an HIE Tool Helped an FQHC Boost Care Coordination
A query-based HIE solution helped an FQHC improve cervical cancer screening rates by 23 percent while streamlining care coordination workflows. Continue Reading
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Feature
26 Apr 2023
How a Statewide HIE Streamlines Care Coordination for Children in Foster Care
A partnership between DCFS and the Arkansas statewide HIE is helping improve care coordination for children in foster care through automated reports. Continue Reading
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News
19 Apr 2023
Large Health IT Networks Unveil Plans to Become QHIN Under TEFCA
Joining as a QHIN under TEFCA intends to provide greater interoperability offerings and allow organizations to participate in a network that works together to share clinical data. Continue Reading
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News
23 Mar 2023
Epic EHR Integration Looks to Streamline Genetic Testing Access
The Epic EHR integration will allow providers to access genetic testing information within their clinical workflows to support precision medicine. Continue Reading
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Feature
28 Feb 2023
Who are the TEFCA Qualified Health Information Network (QHIN) Candidates?
The TEFCA QHIN applicants' health information networks collectively process billions of annual transactions across all fifty states. Continue Reading
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Feature
08 Feb 2023
How An HIE Approaches Continuous Patient Data Quality Improvement
An HIE in Tennessee has tapped an AI-based platform to reduce duplicate patient EHRs as part of its patient data quality improvement efforts. Continue Reading
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Feature
02 Feb 2023
How a Customized EHR Implementation with RCM Boosted Practice Growth
Marrying revenue cycle management (RCM) and clinical workflows through a customized EHR implementation helped a pain management practice streamline efficiencies. Continue Reading
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Feature
10 Jan 2023
What Distinguishes HIEs From Health Data Utilities (HDUs)?
Reshaping the nation's HIEs as state-designated health data utilities (HUDs) offers distinct advantages for public health, according to HIE officials. Continue Reading
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Feature
14 Dec 2022
How a Primary Care EHR Integration Enhanced SDOH Documentation
Adding a social determinants of health (SDOH) screening EHR integration has tripled SDOH documentation within patient records at Memorial Primary Care. Continue Reading
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Feature
12 Dec 2022
How California Is Approaching HIE to Improve Statewide Interoperability
New state legislation aims to enhance interoperability through a statewide HIE that will include clinical and social determinants of health (SDOH) data. Continue Reading
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Feature
06 Oct 2022
How HIEs Can Empower Patient Data Access, Boost Health Equity
The Ciitizen Cures Gateway aims to help HIEs and other data providers support patient data access and comply with information blocking regulations. Continue Reading
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Feature
29 Sep 2022
How a Michigan HIE is Working Towards SDOH Interoperability
Six social care referral vendors have signed a pledge with Michigan’s HIE to support SDOH data exchange and an interoperable social care environment. Continue Reading
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27 Jul 2022
How Health Information Exchange Can Support Public Health, Equity
While traditional patient care is a bread-and-butter HIE use case, public health organizations can also benefit from HIE, according to an Indiana HIE executive. Continue Reading
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Feature
01 Jul 2022
How a Unified EHR Implementation Can Boost Interoperability, Efficiencies
An EHR implementation at a New Hampshire community hospital is set to enhance interoperability and the patient experience. Continue Reading
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Feature
07 Feb 2022
How HIEs Support Interoperability Use Cases for Payers, Providers
ClinicalConnect Health Information Exchange (CCHIE) knows interoperability is important not only for providers, but for payers, too. Continue Reading
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Definition
03 Feb 2022
electronic intensive care unit (eICU)
An Electronic Intensive Care Unit (eICU) is a form or model of telemedicine where state-of-the-art technology is used to provide an additional layer of critical care service to patients. Continue Reading
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Definition
11 Mar 2021
digital health (digital healthcare)
Digital health, or digital healthcare, is a broad, multidisciplinary concept that includes concepts from an intersection between technology and healthcare. Continue Reading
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Definition
04 Feb 2020
Project Nightingale
Project Nightingale is a controversial partnership between Google and Ascension, the second largest health system in the United States. The partnership, which began in 2018, has provided Google with access to the medical records of over 50 million people. Continue Reading
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Definition
13 Dec 2018
Change Healthcare
Change Healthcare is a healthcare technology provider of revenue cycle management, payment management and health information exchange (HIE) solutions. Continue Reading
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Definition
29 Aug 2018
registered health information technician (RHIT)
A registered health information technician (RHIT) is a certified professional who stores and verifies the accuracy and completeness of electronic health records. Continue Reading
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Definition
30 Jul 2018
Cerner Corp.
Cerner Corp. is a public company in North Kansas City, Mo., that provides various health information technologies, ranging from medical devices to electronic health records (EHR) to hardware. Continue Reading
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Definition
22 Jun 2018
Health IT (health information technology)
Health IT (health information technology) is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry. Continue Reading
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Definition
26 Mar 2018
RHIA (Registered Health Information Administrator)
An RHIA, or registered health information administrator, is a certified professional who oversees the creation and use of patient health information, including analyzing that data. Continue Reading
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Definition
26 Jan 2018
Epic Systems
Epic Systems is one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records. Continue Reading
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Definition
28 Nov 2017
electronic health record (EHR)
An electronic health record (EHR) is an individual's official health document that is shared among multiple facilities and agencies. Continue Reading
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Definition
17 Aug 2017
Allscripts
Allscripts is a vendor of electronic health record systems for physician practices, hospitals and healthcare systems. Continue Reading
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Definition
24 Feb 2017
PHI breach (protected health information breach)
A PHI breach is unauthorized access, use or disclosure of individually identifiable health information that is held or transmitted by a healthcare organization or its business associates. Continue Reading
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Definition
25 Jul 2016
Meditech (Medical Information Technology Inc.)
Meditech (Medical Information Technology Inc.) is an electronic health record vendor that holds a 19% market share in the hospital industry, but faces intense competition. Continue Reading
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Definition
17 Feb 2011
ambulatory medical record (AMR)
An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital. Continue Reading
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Tip
16 Apr 2010
Products meeting CCHIT ARRA certification standards
Using products that meet the preliminary certification standards of the American Recovery and Reinvestment Act of 2009 is required for reimbursement under the ARRA legislation. Continue Reading
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News
04 Mar 2010
National health IT policy coordinator ready to implement rules
David Blumenthal, the national coordinator for health IT policy, said at HIMSS10 that his work is starting to shift from drafting regulations to implementing and supporting them. Continue Reading