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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News
02 Dec 2024
EHR documentation of SDOH rising among family physicians
While structured EHR documentation of SDOH is on the rise, future efforts are needed to understand how often structured data elements are mapped to consensus-based standards. Continue Reading
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Feature
27 Nov 2024
Supporting the patient experience during EHR implementation
EHR implementation can improve the patient experience by consolidating multiple systems and enhancing access to personal health data through a single portal. Continue Reading
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Podcast
27 Nov 2024
Driving community health center sustainability with health IT
A partnership between OCHIN and OSIS aims to enhance EHR strategies for community health centers as they face rising costs, staff shortages and increasingly complex patient care. Continue Reading
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News
19 Nov 2024
Digital Health Most Wired: Health IT budgets doubled in 2024
The 2024 Digital Health Most Wired survey revealed significant increases in health IT budgets, adoption of patient engagement tools and a stronger emphasis on cybersecurity. Continue Reading
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Feature
18 Nov 2024
Harnessing SOGI data to advance patient-centered care
While sexual orientation and gender identity (SOGI) data collection informs patient-centered care, it also fuels research efforts to address LGBTQ+ care disparities. Continue Reading
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Feature
04 Nov 2024
How generative AI in healthcare is helping cut admin burden
Over 90% of healthcare workers feel optimistic about the promise of generative AI in healthcare to alleviate administrative burdens, according to a new survey. Continue Reading
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News
30 Oct 2024
Oracle Health to release next-generation EHR in 2025
The next-generation Oracle Health EHR, which incorporates AI across 'the entire clinical workflow,' will be available to early adopters in calendar year 2025. Continue Reading
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News
29 Oct 2024
EHR integration drives ambient speech purchasing decisions
Healthcare organizations are prioritizing EHR integration and usability when selecting ambient speech technology, with top picks including Nuance and Abridge. Continue Reading
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Definition
21 Oct 2024
What is an electronic health record (EHR)?
An electronic health record (EHR) is an individual's official health document that's shared among multiple facilities and agencies. Continue Reading
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Feature
07 Oct 2024
5 EHR implementation challenges and how to overcome them
EHR implementation is no small feat, but being aware of common challenges can help prepare healthcare organizations for successful health IT deployments. Continue Reading
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Definition
07 Oct 2024
What is PHI (protected or personal health information)?
Protected health information (PHI), also referred to as 'personal health information,' is the demographic information, medical histories, test and laboratory results, physical and mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care. Continue Reading
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Feature
30 Sep 2024
9 best practices for successful EHR implementation
Successful EHR implementation requires meticulous planning, strong communication and effective training to navigate complexities and ensure a smooth transition. Continue Reading
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News
30 Sep 2024
Epic calls on Particle Health to release dispute resolution
Epic Systems urges Particle Health to release resolution details on a patient data dispute following Particle Health's antitrust lawsuit against the EHR vendor. Continue Reading
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News
25 Sep 2024
VA EHR has seen 826 major performance incidents since launch
The new VA EHR system, deployed by Oracle Health, has faced over 800 major performance incidents since October 2020, affecting patient care and delaying implementation. Continue Reading
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Definition
24 Sep 2024
What is Change Healthcare?
Change Healthcare is a healthcare technology provider specializing in revenue cycle management, payment management and health information exchange solutions. Continue Reading
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News
23 Sep 2024
Particle Health sues Epic Systems over antitrust violations
Particle Health has filed a federal antitrust lawsuit against Epic Systems, accusing the EHR giant of practices that block competition and harm patient care. Continue Reading
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News
17 Sep 2024
Most small practices say core health IT vendors fall short
According to a KLAS report, many small practices report that their core health IT vendors lack key functionalities beyond EHR and practice management, including telehealth. Continue Reading
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Definition
11 Sep 2024
What is digital health (digital healthcare)?
Digital health, also known as digital healthcare, is the use of digital technologies in healthcare. Continue Reading
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News
09 Sep 2024
Half of clinicians report positive ambient AI experience
About half of clinicians using an ambient AI documentation tool in a clinical trial reported positive outcomes, but some found no time-saving benefits or improved EHR experience. Continue Reading
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News
27 Aug 2024
Team-based EHR documentation cuts physician EHR time
A 'JAMA Internal Medicine' study found that team-based documentation increased visit volume and reduced physician EHR documentation time, especially after a 20-week learning period. Continue Reading
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Feature
23 Aug 2024
How ambient AI can improve the patient-provider relationship
Ambient AI technology is helping Ochsner Health improve patient-provider relationships by allowing clinicians to spend consultation time looking at their patients rather than a computer screen. Continue Reading
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Feature
09 Aug 2024
The promise and perils of GenAI in clinical documentation
Generative AI in clinical documentation can ease EHR burdens and enhance patient communication, but issues with accuracy necessitate careful provider review. Continue Reading
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Feature
05 Aug 2024
How AI in nursing could alleviate documentation burden
As nurses face increasing levels of burnout, researchers are exploring how large language models could streamline clinical documentation and care planning. Continue Reading
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Definition
17 Jul 2024
Epic Systems
Epic Systems, also known simply as Epic, 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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Podcast
15 Jul 2024
Advocating for SDOH data standards to support health equity
Healthcare stakeholders have successfully advocated for updated race and ethnicity data standards, but more work is needed to ensure inclusive data collection for health equity. Continue Reading
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Definition
11 Jul 2024
national provider identifier (NPI)
A national provider identifier (NPI) is a unique ten-digit identification number required by the Health Insurance Portability and Accountability Act (HIPAA) for covered healthcare providers in the United States. Continue Reading
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Definition
18 Jun 2024
clinical data analyst
A clinical data analyst -- also referred to as a 'healthcare data analyst' -- is a healthcare information professional who verifies the validity of scientific experiments and data gathered from research. Continue Reading
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News
17 Jun 2024
VA extends Oracle Health EHR modernization contract
The Department of Veterans Affairs has extended its EHR modernization contract with Oracle Health, focusing on improved system performance accountability. Continue Reading
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Definition
11 Jun 2024
clinical documentation
Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test. Continue Reading
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News
28 May 2024
3 healthcare organizations begin EHR implementation projects
Health First, Axis Health and Atlantis Orthopedics recently announced EHR implementation projects to improve patient care and optimize clinical workflows. Continue Reading
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News
17 May 2024
Large organizations drove 2023 acute care EHR market energy
While acute care EHR purchasing remained high throughout 2023, Epic was the only health IT vendor to achieve a net increase in acute care EHR market share. Continue Reading
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News
13 May 2024
3 care orgs pursue interoperability with Epic EHR systems
Albany Medical Center, WVU Medicine Thomas Hospitals, and Vanderbilt Home Care have recently announced Epic EHR implementations to support health data interoperability. Continue Reading
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Feature
15 Apr 2024
How The Sequoia Project is promoting health data usability
The Sequoia Project's Taking Root Initiative is looking to address health data usability issues across the industry, ranging from human factors to technical challenges. Continue Reading
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Feature
04 Apr 2024
How Regenstrief and HL7 are driving SDOH data standards
The Regenstrief Foundation has committed $4.4 million toward an expanded partnership with the HL7 Gravity Project to create SDOH data standards. Continue Reading
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News
20 Mar 2024
KLAS: Epic leads EHR mindshare for independent ambulatory care orgs
Epic and athenahealth are dominating EHR mindshare across independent ambulatory care organizations, according to a new KLAS report. Continue Reading
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News
18 Mar 2024
Arkansas Heart deploys Oracle Health EHR to enhance interoperability
The Oracle Health EHR implementation aims to improve patient outcomes by enhancing health data interoperability across Arkansas Heart's network of ambulatory clinics and two hospitals. Continue Reading
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Definition
11 Mar 2024
What is Current Procedural Terminology (CPT) code?
Current Procedural Terminology (CPT) is a medical code set that enables physicians and other healthcare providers to describe and report the medical, surgical, and diagnostic procedures and services they perform to government and private payers, researchers and other interested parties. Continue Reading
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News
11 Mar 2024
VA announces joint EHR deployment with DoD during EHRM program reset
VA is rolling out the federal EHR system at a joint-DoD healthcare facility despite pausing additional go-lives as part of its EHR modernization (EHRM) reset. Continue Reading
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News
04 Mar 2024
Frederick Health Taps MEDITECH EHR Integration for Precision Medicine
The MEDITECH EHR integration allows Frederick Health providers to order genetic tests and analyze discrete results directly within the Expanse platform. Continue Reading
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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
26 Feb 2024
SC Health System Invests $40M in Epic EHR Platform for Interoperability
The Epic EHR implementation is set to advance interoperability across the health system, allowing providers to access patient data more easily for care coordination. Continue Reading
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News
20 Feb 2024
VA OIG Flags Medication Safety Issues with Oracle Health EHR System
According to VA OIG, the Oracle Health EHR is posing medication safety issues for veterans through duplicative, inaccurate, or missing medication data. Continue Reading
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Definition
14 Feb 2024
medical scribe
A medical scribe is a professional who specializes in documenting patient encounters in real time under the direction of a physician. 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
09 Jan 2024
Interwell Health Adds 8 Practices to Nephrology-Focused Epic EHR System
The Epic EHR configuration aims to foster collaboration between nephrology practices, hospitals, and dialysis centers for value-based care. Continue Reading
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News
05 Jan 2024
Nine Healthcare Orgs Join OCHIN Epic EHR Network to Drive Care Access
The OCHIN Epic EHR platform aims to meet the needs of community-based healthcare providers and enhance care access across underserved populations. Continue Reading
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News
21 Dec 2023
Epic EHR Implementation Projects Look to Boost Patient Experience
Healthcare organizations in Minnesota, Missouri, and Nebraska have recently announced Epic EHR implementation projects aimed at improving patient experience. Continue Reading
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News
07 Dec 2023
Veteran's Lawsuit Alleges VA EHR Defects Delayed Cancer Diagnosis
A veteran is seeking unspecified monetary damages from the federal government and the vendors behind the VA EHR system due to alleged system flaws. Continue Reading
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News
30 Nov 2023
Health System Selects MEDITECH EHR Implementation for Interoperability
A health system in Savannah, Georgia, has opted for a MEDITECH EHR implementation to drive health data interoperability across care settings. Continue Reading
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News
17 Nov 2023
VA Reports Improved Oracle Health EHR Performance, But Snags Remain
While there has not been a total outage of the VA Oracle Health EHR for six months, frontline healthcare workers continue to experience pauses in the system. Continue Reading
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News
16 Nov 2023
Community Hospitals Select Oracle Health EHR to Streamline Workflows
Community hospitals in Iowa, Kentucky, and Tennessee have implemented the Oracle Health CommunityWorks EHR to optimize clinical workflows and drive interoperability. Continue Reading
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News
13 Nov 2023
Indian Health Service Taps Oracle Health EHR Implementation for HIE
The enterprise platform from EHR vendor Oracle Health is set to drive care coordination and patient safety through enhanced health information exchange (HIE). Continue Reading
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News
09 Nov 2023
KY Hospital Receives Epic Award for EHR Implementation Success
EHR vendor Epic gives its annual Good Install award to one new customer who stands out above others in terms of EHR implementation success. Continue Reading
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News
08 Nov 2023
Department of Mental Health Taps Oracle Health EHR for Interoperability
The Oracle Health EHR implementation aims to enhance interoperability across the Missouri Department of Mental Health’s facilities and contracted agencies. Continue Reading
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News
31 Oct 2023
Surgery Center Selects eClinicalWorks EHR to Drive Interoperability
The implementation of the eClinicalWorks EHR is set to advance interoperability with ambulatory surgery centers and other providers to boost care coordination. 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
16 Oct 2023
ENT Practice Increases Patient Engagement with eClinicalWorks EHR
An Arizona-based ENT practice has boosted patient engagement through questionnaires and various payment options within its eClinicalWorks EHR system. 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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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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News
05 Oct 2023
NY Orthopaedic Practice Taps athenahealth EHR for Interoperability
An orthopaedic practice based in Albany, NY, selected a cloud-based EHR from athenahealth to enhance health data interoperability. Continue Reading
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Feature
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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Feature
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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News
29 Sep 2023
VT Health System Streamlines Health IT Strategy with MEDITECH EHR
Gifford Health Care is replacing three legacy health IT systems with a MEDITECH EHR to enhance operational efficiency and clinical decision support. 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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News
18 Sep 2023
UPMC Moves to Single Epic EHR to Boost Health Data Interoperability
The unified Epic EHR platform is set to enhance health data interoperability across the UPMC enterprise for improved access to patient data. 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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News
14 Sep 2023
VA Plans to Resume Oracle Cerner EHR Modernization in Summer 2024
At a recent House hearing, VA and Oracle Cerner officials said they expect to restart the agency’s $10 billion EHR modernization in the summer of 2024. Continue Reading
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News
13 Sep 2023
Senate Appoints VA Deputy Secretary to Lead EHR Modernization Project
In her new role as deputy secretary, Tanya Bradsher will oversee the troubled VA EHR modernization program launched in October 2020. Continue Reading
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News
12 Sep 2023
Oracle Stock Falls in Part Due to Cerner EHR Revenue Weakness
As the technology vendor moves Cerner EHR clients to cloud subscriptions, Safra Catz, Oracle CEO, warned of near-term weakness in revenue growth. Continue Reading
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News
11 Sep 2023
OIG: VA Lacked Timelines for Cerner EHRM Progress Reports
OIG found that Cerner did not have deadlines for corrections to VA EHRM progress reports, which could have limited VA’s ability to manage deliverables. Continue Reading
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Feature
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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News
06 Sep 2023
Investment Firm Acquires Health IT Vendor NextGen Healthcare
Upon completing the deal with software investment firm Thoma Bravo, NextGen Healthcare will be a privately held health IT company. Continue Reading
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News
01 Sep 2023
Pediatric Provider Taps MEDITECH Expanse EHR to Drive Interoperability
The MEDITECH Expanse EHR implementation will support interoperability of patient health data for care coordination across Bethany Children's Health Center. Continue Reading
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News
29 Aug 2023
VA CIO Hopeful Revised Oracle Cerner Contract Will Mend EHR Project
Kurt DelBene, VA CIO, is “cautiously optimistic” that stronger Oracle Cerner contract terms will set the EHR modernization on the right path. Continue Reading
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News
28 Aug 2023
EHR Vendor NextGen Exploring Sale of Company, Sources Say
On the heels of a $31 million settlement with the DOJ, EHR vendor NextGen Healthcare is reportedly considering a sale of the company. Continue Reading
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News
18 Aug 2023
Nashville Hospital Swaps Multiple EHR Systems for Oracle Community Works
Nashville General Hospital will switch out multi-EHR systems moving forward with Oracle Cerner CommunityWorks for a single EHR. 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
08 Aug 2023
Legislators Introduce Act for Behavioral Health IT Adoption
The bipartisan act would provide $20 million a year in grant funding over five fiscal years to finance behavioral health IT adoption. Continue Reading
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News
04 Aug 2023
SoutheastHEALTH Joins Mercy, Gaining Access to Epic EHR System
A definitive agreement between Mercy and SoutheastHEALTH will merge the health systems, providing the latter access to the Epic EHR system. Continue Reading
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News
02 Aug 2023
House Legislators Propose $1.9B VA EHR Budget for 2024
If passed by the Senate, the bill would allocate $1.9 billion to the VA EHR modernization in fiscal year 2024, including $253 million for program management. 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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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
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
19 Jul 2023
Oklahoma Proposes Opt-Out Provision in Updated Statewide HIE Rules
After the Governor rejected Senate Bill 1369, the subsequent rule changes now exempt healthcare providers from mandatory participation in the statewide HIE. Continue Reading
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News
18 Jul 2023
NextGen Healthcare Pays $31M to Resolve False Claims Act Violations
NextGen Healthcare allegedly breached the False Claims Act, falsely certifying and misrepresenting EHR software capabilities to exploit federal incentives. 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
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
11 Jul 2023
WV Practice Taps Oracle Health EHR for Health Data Interoperability
The Oracle Health EHR implementation is set to support health data interoperability across Vandalia Health medical clinics for care coordination. 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
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
30 Jun 2023
FQHC Implements eClinicalWorks EHR to Enhance Clinical Documentation
The FQHC has selected an eClinicalWorks EHR platform to streamline clinical documentation and drive value-based care delivery. 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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News
27 Jun 2023
VA to Maintain Hospital Staff Amidst Budget Deficit Linked to EHR
According to a VA official, the agency is providing extra funding to hospitals in Spokane and Walla Walla to address budget shortfalls related to the new EHR system. Continue Reading
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News
23 Jun 2023
VA Confident in EHRM Despite Reported Oracle Cerner Layoffs
Recent layoffs at Oracle Cerner are reportedly due to challenges the EHR vendor has faced with the $10 billion VA EHR modernization (EHRM) project. Continue Reading
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News
21 Jun 2023
Provider Orgs Deploy eClinicalWorks EHR Systems for Care Coordination
A Washington-based pain management clinic has implemented an eClinicalWorks EHR to drive efficiency and care coordination. Continue Reading
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News
20 Jun 2023
ONC Project Taps FHIR to Extract Over 40% of Clinical Data Registry
ONC revealed that using the FHIR to leverage data shows promise for the acquisition of clinical registry data, reducing processing times and improving submission delays. 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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News
19 Jun 2023
Oracle Reportedly Lays Off Hundreds of Cerner Healthcare Employees
The reported layoffs within the Cerner Healthcare unit come days after Oracle announced quarterly revenue increases of 17 percent compared to last year. Continue Reading
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News
12 Jun 2023
Epic Leads Medical Oncology EHR Market in Customer Satisfaction
Amidst market consolidation, Epic has worked to build more robust medical oncology EHR functionality, including developments in patient oncology history and treatment plans. Continue Reading
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News
09 Jun 2023
Ohio Hospital Goes Live with MEDITECH Expanse EHR
The newly launched MEDITECH Expanse EHR aims to boost functionality and interoperability, guiding clinical decisions with a full view of patient health histories. Continue Reading