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
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
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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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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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
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News
08 Jun 2023
VA Official: Staff Cuts Not Needed to Fix EHR-Related Budget Deficit
Hiring at the Mann-Grandstaff VA Medical Center will be subject to “considerable scrutiny" to address the EHR-related budget deficit, according to VA's Northwest regional director. Continue Reading
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News
02 Jun 2023
Three Provider Organizations Launch eClinicalWorks EHR Implementations
Indiana Health Centers, New Life Health & Concierge in Texas, and Be Well Primary Care in Texas recently began their eClinicalWorks EHR implementations. Continue Reading
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News
01 Jun 2023
Senator Questions Deputy Secretary Nominee on VA EHRM Oversight
The renegotiated VA EHRM contract includes “30-times stronger penalties” for Oracle Cerner, according to VA deputy secretary nominee Tanya J. Bradsher. Continue Reading
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News
25 May 2023
Contexture HIE Partners with Verato to Support Patient Matching
Contexture HIE has tapped Verato's data management solution to bolster patient matching in Arizona and Colorado, tackling a multi-billion-dollar healthcare challenge of accurate record linkage. Continue Reading
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News
25 May 2023
Congresswoman Demands VA Prevent Hospital Cuts for EHR Issues
In a letter to the VA secretary, Rep. Cathy McMorris Rodgers (R-WA) emphasized that struggling VA hospitals using the EHR need more personnel and resources, not less. Continue Reading
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News
22 May 2023
Flawed EHR Contributes to $35M Budget Shortfall at VA Medical Center
The Mann-Grandstaff VA Medical Center director informed supervisors that the hospital would be forced to reduce its staff to compensate for budget shortfalls linked to the new EHR system. Continue Reading
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19 May 2023
Provider Orgs Move Ahead with MEDITECH, eCW EHR Implementations
Three provider organizations have tapped MEDITECH and eClinicalWorks for EHR implementations aimed at improving patient engagement, reducing IT costs, and bettering care quality. Continue Reading
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News
19 May 2023
Senate Democrat Questions VA Secretary on Renegotiated EHR Contract
At a recent Senate Veterans’ Affairs Committee hearing, Senator Patty Murray (D-WA) pressed VA officials on the modified EHR contract and how VA plans to assess end-user satisfaction. Continue Reading
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News
11 May 2023
Community Connect Paves Way for Two Hawai'i Hospitals Epic EHR Go-Live
Utilizing the Community Connect program, two Hawai'i hospitals tapped into Epic EHR through a nearby larger hospital, bypassing the usual high implementation costs. Continue Reading
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News
10 May 2023
KLAS: Kept Promises Key for Health IT Vendor Customer Satisfaction
According to KLAS research, health IT customer satisfaction hinges on fulfilled vendor promises and aligned expectations during the sales process. Continue Reading
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News
05 May 2023
Community Health Center Taps athenahealth EHR to Improve Patient Experience
Three healthcare organizations are preparing for upcoming EHR implementations, with athenahealth, MEDITECH Expanse, and eClinicalWorks as their respective vendors. Continue Reading
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News
28 Apr 2023
Interoperability a Key Factor in Referral Decisions for Post-Acute Care
New survey findings revealed that electronic orders and interoperability drive post-acute care referral decisions for 99 percent of hospitals and physicians, yet progress in these areas remains limited. Continue Reading
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News
28 Apr 2023
VA, DoD Clinicians Experience Additional Oracle Cerner EHR Outage
Denis McDonough, VA secretary, told members of the Senate Appropriations Committee that the Oracle Cerner EHR outage lasted for 224 minutes. Continue Reading
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News
27 Apr 2023
House Lawmakers Introduce Legislation for VA EHRM Reform
The bill would require VA to ensure it meets performance baselines at VA medical centers currently using the Oracle Cerner EHR before continuing the EHRM. Continue Reading
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News
27 Apr 2023
Three Healthcare Organizations Share Upcoming EHR Implementation Plans
A mental health organization in New York, a 22-provider practice in Arizona, and a family medicine practice in Massachusetts recently revealed EHR implementations prioritizing record management. Continue Reading
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News
26 Apr 2023
WA Congresswoman Calls on VA to Terminate Oracle Cerner EHR System
Days after VA announced a reset of its EHRM project, Cathy McMorris Rodgers (WA-05) called for the agency to “pull the plug” on the Oracle Cerner EHR system. 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
24 Apr 2023
VA Suspends Further Oracle Cerner EHR Implementations for EHRM 'Reset'
The EHRM reset aims to help VA focus resources on system optimization at sites where the Oracle Cerner platform is currently used before continuing EHR implementations. 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
18 Apr 2023
Latest FHIR Standard R5 Elevates Data Exchange, Interoperability
The newly released FHIR standard R5 contains thousands of incremental updates to enable advanced interoperability and streamline data exchange across disparate health systems. Continue Reading
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News
14 Apr 2023
Adverse EHR Implementation Sentiments Can Linger One to a Year Post-Launch
A KLAS report revealed 50 percent of provider organizations faced EHR implementation challenges like mismatched expectations, impacting provider satisfaction and causing long-lasting negative feelings. Continue Reading
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News
13 Apr 2023
Healthcare Orgs Select Integrated EHR Platforms for Interoperability
An orthopedic practice in New England recently moved to an integrated EHR platform to enhance interoperability and streamline clinical workflows. Continue Reading
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News
12 Apr 2023
DHA Conducts Market Research for EHR Implementation Follow-On Contract
A DHA contracting notice asks vendors to demonstrate their capacity to work at the scale necessary for the multibillion-dollar EHR implementation. Continue Reading
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News
07 Apr 2023
VA Extends Pause on Rollout of Oracle Cerner EHRM Project
As VA looks to renegotiate the terms of its EHRM contract with Oracle Cerner, the agency has pushed off its planned June go-live in Saginaw, Michigan. Continue Reading
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News
06 Apr 2023
Several Healthcare Orgs Announce EHR Implementation for Distinct Goals
Morris Hospital in Illinois, Coryell Health in Texas, and Palm Plastic Surgery & Medspa in Florida launched new EHR implementations with MEDITECH, Oracle Cerner, and eClinicalWorks, respectively. Continue Reading
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News
04 Apr 2023
DoD MHS GENESIS EHR Implementation Heads Down the Homestretch
DoD officials said that MHS GENESIS EHR implementation has gone live at 75 percent of clinics and hospitals, catering to 160K users and 6.1M beneficiaries. Continue Reading
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News
03 Apr 2023
MO Hospital Integration Sparks $6.5M Epic EHR Implementation
Perry County Health System tapped an Epic EHR implementation. Meanwhile, an FQHC in Kentucky and a specialty group in Pennsylvania have tapped eClinicalWorks for an EHR system. Continue Reading
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News
29 Mar 2023
House VA Chair Calls for Crack Down on Management of EHRM
Rep. Mike Bost (R-Ill) blamed much of the troubled VA EHRM on the vendors behind the health IT, saying they “need to get their act together." Continue Reading
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News
28 Mar 2023
Epic Community Connect Leads for FQHC EHR Functionality, Satisfaction
Epic Community Connect clients said the solution is evolving to meet their needs and expect the vendor to continue adding FQHC EHR functionality. Continue Reading
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News
28 Mar 2023
AWS, Azure Shine as Front Runners for Epic Orgs During Cloud Migration
Amid the cloud migration trend, early Epic adopters lean toward Microsoft Azure for existing ties with the vendor, while AWS gains consideration for its Epic expertise and technical resources, KLAS found. Continue Reading
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News
24 Mar 2023
Northwell Health Selects Epic Systems for EHR Implementation
The Epic Systems EHR implementation aims to unify Northwell Health patient records across all venues, streamlining care coordination for patients and providers. 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