Changes in Clinical Documentation

While at AHIMA 2012, I had a chance to sit down with Dr. Jon Elion, Founder and CEO of ChartWise Medical Systems. I asked him about the changes in clinical documentation he’s seeing and I grabbed a video of his answer below. His answer was an interesting and insightful look into clinical documentation and ways that coding is effecting the clinical documentation.

I find Dr. Elion’s answer quite interesting in the terms of using clinical documentation intelligence in EHR. Add in things like coding engines, NLP, and EMR templates and you can see why getting the documentation right is a challenge even in an IT optimized world.