Clinical Narrative

The Tale of Prompt Engineering Gone Wild! This month’s episode of “News you can Use” on HealthcareNOWRadio features news from the month of July 2023 As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners. This month we open with a detailed discussion of the recently published […]

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January 25, 2021

Capture the Story

Soundcloud Meets Rap Genius This week I am talking to Shiv Rao, MD (@ShivdevRao) is the co-founder and CEO of Abridge (@ABridgeHQ), which uses groundbreaking machine learning to help people understand the details of their care and follow through on their doctors’ advice. He is also a faculty member and practicing cardiologist at UPMC’s Heart and Vascular Institute. Shiv […]

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Unlocking Data Potential In this special episode I am talking with David Lareau, CEO, Jay Anders, MD Chief Medical Officer and Toni Laracuente, RN Chief Nursing Officer all from Medicomp Systems. We discuss the challenge in healthcare of getting data to the clinical team that need it – so much of the content that has been created in the […]

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Open Clinical Systems This months episode of “News you can Use” in the traditions of “Ask Me Anything” on HealthcareNOWRadio features news from the month of October 2019 You can read more about the series here and the concept of keeping up with innovating in healthcare. Please send me your suggestions on topics you’d like to see covered. You can […]

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The Panel “The Art of Medicine” Panel (part of the Art of Medicine campaign) took place yesterday from 9 – 11am at the Boston’s W Hotel, 100 Stuart St, Boston, MA Our panelists from Left to Right John D. Halamka, MD, MS, CIO of Beth Israel Deaconess Medical Center (and Life as  healthcare CIO blog and @jhalamka) Keith Dreyer, DO, […]

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Many years ago I remember an excited friend who worked for one of the vendors of electronic medical records (really this was more of a billing and patient tracking and management system than and Electronic Health record) desperate to show me some of their new applications – in particular a module they had developed to […]

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We know doctors are under an ever increasing load may eventually break their backs..if nothing else its increasing the overall pain In a recent study of physician attitudes toward clinical documentation technology and processes clinicians the majority of clinicians said they would be more responsive to Clinical Documentation Improvement (CDI) clarifications if they were delivered […]

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A recent article in Becker Hospital Review:  Technology Should Aid Human Interaction: Q&A with Dr. Nick Terheyden, CMIO of Nuance featured some important points to make Health IT needs to fade into the background. It needs to become part of the fabric of the office rather than the focal point, and then the interaction will change […]

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Awesome video put together showcasing the various aspects of clinical documentation and why it is so important to capture the complete patient story in narrative form Putting all the details means capturing the diabetes and loss of consciousness Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of […]

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We are facing significant changes to the world of clinical documentation with the big push encompassed in the Meaningful Use requirements that push provides and healthcare facilities inexorably towards an electronic medical record (EMR) but there remain significant concerns over the potential impact these solutions can and will have on our clinical documentation. In this […]

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We are on a path to roll out a large swathe of Electronic Health Records (EHR) but a recent report published on the AISHealth.com Audits of Electronic Health Records Cloning Reveal Documentation Problems That Put Compliance at Risk will give many folks reasons to pause and consider their strategy in rolling out electronic medical records […]

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Medicine is complex and providing the best possible care is a challenge, and it is getting more complex on a daily basis. I’m willing to bet that at least a few readers will still hold onto the belief that playing music, in particular Mozart, can improve brain function. IN fact searching Google Scholar reveals about […]

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Thought critical free-text physician notes are under threat in the current slew of Electronic Medical Records and are at risk of being washed away in the rush towards the digitization of medical records. In Jeff Barry’s article in Health Management Technology; “Value of Unstructured patient narrative” he cites examples of Throwing the patient out with […]

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Download now or preview on posterous Clinical Narrative Integrated into the EHR – Nick van Terheyden.pdf (1178 KB) From Health Data Matrix August 2009: Clinical Narrative Integrated into the EHR – Harmony with Healthstory It’s been 40 years since we placed a man on the moon. It was a big step forward for mankind. We even had a […]

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Hidden in an article that reviewed nursing opinions on computerized records: (AFT: Nurses Express Mixed Opinions on Computerized Records) was a striking data point While 73 percent said implementation of the systems went smoothly, many problems were identified, including 52 percent who said physicians are refusing to use the new systems. Yikes – that alone […]

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Pauline Chen wrote a piece in the NY Times on April 22, 2010 titled: An Unforeseen Complication of Electronic Medical Records which in many respects is an understatement. There are many untended consequences big and small and while the appreciation of the benefits: fewer missing charts streamlined information and efficient work-flow patterns It was with […]

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Everyone agrees we need codified structured data for problem lists, medication, allergies and labs…….or do they? John Halmka wrote a piece for HealthcareIT News earlier this month titled “Rethinking Clinical Documentation” in which he asks what is the role of unstructured clinical documentation text In many instances there has been an attempt to drive unstructured […]

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