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Clinical Documentation Systems

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BayScribe  BayScribe is an end-to-end, fault-tolerant Clinical Documentation Solution, complete with Natural Language Processing for Coding & CDI, plus Dictation, Transcription, Speech Recognition & Document delivery for all your...
BayScribe Structured Data for Meaningful Use available now!
BayScribe CDI Tools Clinicial Documentation Improvement meets BayScribe.
Henry Schein MicroMD  Medical Practice Management Software, HIPAA Medical Compliance Practice Management Software, EMR Software, EMR System Software, Small Practice Software, EMR Systems for Small Practices, Physician Practice Software,...
MicroMD EMR Electronic Medical Records
Records One  Records One is a developer of technology that aids in the creation and use of clinical documentation to improve efficiency throughout the continuum of care.
RecordsOne Structured Data for Meaningful Use available now!
RecordsOne Solutions The complexity of Clinical Documentation is increasing as are the demands for accurate documentation in support of appropriate reimbursement. Facilities are...
Clinical Computing  Founded in 1979, Clinical Computing was an early innovator of clinical databases that evolved into point of care clinical information systems. Since that inception we have become an international organization delivering...
Clinicalvision V A reporting module that significantly reduces time spent with compliance reporting
Innovative Healthcare Solutions, Inc  Innovative Healthcare Solutions (IHS) specializes in the McKesson financial and clinical products including the 10.1 Clinical Release and Revenue Cycle Management. Our deep skill services include implementation, project...
Horizon Expert Document Horizon Expert Document
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Speech Understanding solution Clinical documentation uses a wide variety of terms with same meaning. There are terms that sound the same but have different meanings. Physicians have a...
T‐System Technologies, Ltd.  T-System is the nation's largest provider of emergency department (ED) clinical documentation solutions with over 13 years of experience. We offer a variety of electronic and paper-based products to fit your facility's...
T-Sheets The T System offers documentation solutions, –including emergency physician, nursing and order sets templates, – to address a variety of documentation...
Anoto Group AB  Anoto Group is the company behind and world leading in the unique technology for digital pen and paper, which enables fast and reliable transmission of handwritten text into a digital format. Anoto operates through a...
Anoto penDocuments Pro If you need to digitally capture handwritten documents, scanners are not your only option. Anoto penDocuments Pro uses Digital Pen and Paper technology to...
Meta Pharmacy Systems  For more than 20 years, Meta has been designing and developing fully integrated software solutions and hospital information systems to hospitals and other healthcare enterprises to promote and improve patient safety....
MetaCare IntelliDocs MetaCare IntelliDocs™ not only enhances the paper process by correcting problems of legibility, accuracy and avoidance of redundant data entry but also...
American Society of Health-System Pharmacists  ASHP is a 35,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, long-term care facilities, home care, and other components of health care...
American Society of Health-System Pharmacists ASHP is a 35,000-member national professional association that represents pharmacists who practice in hospitals, health maintenance organizations, long-term...
DocuComp LLC  DocuComp helps Hospitals to work with Attending Physicians, Hospitalists & Physicians-in-Training to improve explicit documentation in the medical record. We help you to develop / implement / enhance your Clinical...
DocuComp We are the only organization to offer a nationally recognized Certification in Clinical Documentation Improvement Specialists Program. Having Certified...
DocuEd The Clinical Documentation Institute and Certification Program is the premier educational seminar dedicated to providing practical guidance for clinical...
JATA  JATA has worked with over 500 hospitals and 40,000 physicians across the U.S. to improve their clinical documentation and help them secure appropriate reimbursement for their work. When it comes to healthcare compliance...
CDMP The Compliant Documentation Management Program® (CDMP®) is a fully managed, end-to-end improvement program that touches all the critical aspects of your...
Clintegris CIS is trained to: * Perform hands-on patient assessments. * Identify and secure documentation of POA conditions. * Assist with quality...
Comprehend Systems, Inc.  Comprehend Systems, Inc. was formed in 2010 in California by an entrepreneurial team that has several decades of combined experience with clinical trials and software development. Our mission is to create tools that help...
Comprehend Clinical Comprehend Clinical™’s highlights and filters provide additional insight into the underlying data. Compare specific patient sub-populations, or set...
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Clinical Documentation Systems - Product Reviews

Severity of illness and post-admission complications calculated by Medicare and third-party insurers. Exacting clinical documentation systems are key to medical provider's full reimbursement.

Clinical Documentation Systems are extremely important as Jefferson Regional Medical Center, Pittsburg, PA soon learned. This medical provider recognized that patients being treated at its facilities were sicker than indicated by the organization’s quality outcomes data. More care was being provided, yet patient the facility’s record system indicated less severity than actually existed. Looming problem: Heartland couldn't produce enough medical documentation to satisfy Medicare and other insurers that the cost of care equaled the medical need.

“Realizing the potential impact on Jefferson Regional, the hospital began working to dramatically improve their clinical documentation system,” wrote JoAnne R. Hahey and Mel Tully of Jefferson Regional in their Case Study: The Rewards of Accurate Clinical Documentation. They created a new role of clinical documentation specialist or CDS to assist the process. “A registered nurse with a strong critical care or medical/surgical background, the CDS is charged with concurrent documentation investigation, reviewing and re-reviewing the record while the patient is still in the hospital, and working with the physician to achieve detailed documentation during the patient stay.”

Best-in-Class Clinical Documentation Software features:

  • Offers patient-centered documentation to improve the quality of care
  • Provides integration to reduce overhead and administration costs and provide better patient outcomes.
  • Presents a streamlined workflow to enhance productivity, ensure HIPAA compliance,

Top Considerations before Buying Clinical Documentation Software:

The best clinical documentation system will capture data at point-of-care, thus eliminating duplication and ensuring a more faithful Electronic Health Records (EHR) for the patient and the provider.

Key Products:

1. A wide range of solutions to meet a variety of medical practice needs is Cerner Corporation's answer to the Patient Medical Record Software (PMS) requirements mix. Cerner INet is Cerner's core product for Clinical Documentation and apart of the critical care solution. INet, simplifies  work and eliminates redundancy. Clinicians can document, view and filter data in one location. Claiming to have more than 6,000 clients worldwide, and 900 clinicians for input, Cerner Corporation, incorporated in 1980, offers applications developed around its Health Network Architecture (HNA). HNA allows clinics, hospitals, HMOs, physicians, and integrated health organizations (IHOs) to share clinical and management data across multiple disciplines and facilities.

2. With what it calls a “comprehensive medical practice solution,” MicroMD developed its MicroMD PM which scales to support medical practices as they grow with a full-featured system, including patient information, billing, claims, statements and remittance solutions, scheduling, integrated electronic data interchange (EDI), and reporting tools. All EDI solutions are HIPAA-compliant. The Company's four business groups--dental, medical, international and technology--serve more than 500,000 customers worldwide, including dental practices and laboratories, physician practices and veterinary clinics, as well as government and other institutions.  Founded by Henry and Esther Schein as a storefront pharmacy in 1932, and for the last 25 years as Henry Schein Medical Systems, today MicroMD PM serves physicians, from solo practitioners to large multi-specialty groups with multiple locations, to MSOs, billing services,. and community health centers.

3. AdvancedMD Software, Inc., founded in 1999, provides Web-based, medical practice management solutions for physicians’ offices, management services organizations, medical billing services, medical practice billing and management software for small, group, and enterprise medical providers, IPA, and hospital organizations. Recently reported in TMC HealthCare Technology under the headline “AdvancedMD Enhances Medical Practice Optimization Software Platform,”“AdvancedMD, by investing in Akamai Technology's Web Application Accelerator, was able to provide a consistent, high performance user experience to clinicians and billing service companies across the country and around the globe more cost-effectively.” For example, an offering such as AdvancedMD Medical Billing Software, which is an integral part of the process that interfaces with insurance reporting issues, HIPPA compliance, HCFA codes, CPT codes, and patient payment, is now speedier because of the investment in Akamai.

4. Ingenix, Inc., formerly known as Applied HealthCare Informatics, Inc. and founded in 1996, provides information technology products, services, and consulting in the areas of health and productivity optimization, medication reconciliation, MS-DRG readiness, performance improvement and data analysis, revenue cycle management, care and health management, claim adjudication and reimbursement management, claims management and fraud prevention, and electronic data interchange (EDI). Said to serve more than 250,000 diverse health care clients including insurance companies, federal/state agencies, pharmaceutical and biotech firms, Fortune 500 enterprises, hospitals, and physicians within the health care community. Ingenix also provides solutions in the areas of electronic payments and statements, medical and financial management, network and credentialing, and pharmacy benefit management. The company serves insurance companies and health plans, physicians and healthcare providers, hospitals, corporations, pharmaceutical and biotech companies, and federal and state agencies in the health care industry. For electronic medical billing, for example, there are Ingenix Revenue Cycle Management products, which offer control over coding, compliance, and reimbursement processes, from streamlining admissions to increasing cash flow.

Clinical Documentation Systems
Definition: Clinical Documentation is the process of documenting an individual patient’s clinical history. Clinical documentation systems can expedite the diagnostic process for an individual’s future health concern.


Clinical Documentation Systems Research Library

Billing firm expands services and supports clients with MicroMD PM
Henry Schein MicroMD
“Our goal was finding the best product for the best price. Five years later, I think we did a pretty good job of that. It’s very cost-effective and a good product that fits all of our needs.” Brad Arthur, Director of Operations The Consult, Inc. ORGANIZATION The Consult, based in Cincinnati, provides billing services and practice consulting for over fifty medical practices primarily in Ohio, ...
BayScribe: Savings and Control
BayScribe is a Clinical Documentation System that is provided to healthcare facilities as a service – Software as a Service – relieving facilities of the financial burden to purchase expensive hardware to support Clinical Documentation. There are three key areas of benefit to the facility: Cost, Control and Performance. The focus of this White Paper is Cost and Control and the areas of ...
Case Study – Patient Recruitment with Clinical Conductor Site CTMS at Accel Clinical Services
Accel Clinical Services began using Clinical Conductor Site CTMS in the Fall of 2011. Prior to the implementation of Clinical Conductor Site CTMS, administrators and managers at Accel Clinical Services were using another CTMS system that did not have the functionality, usability or customer support that was required. This case study analyzes the organization, its challenges associated with these ...
Case Study – Integrating Greenphire’s ClinCard™ System as a payment module to Clinical Conductor™ Site CTMS
Three clinical research sites—Sterling Research, The Corvallis Clinic, and The Lehigh Center for Clinical Research—recently integrated Greenphire’s ClinCard™ System into their existing Clinical Conductor™ CTMS workflow. This case study presents the research sites, the challenges of their previous patient payment methods, and the results achieved by implementing the ClinCard™ System to manage ...
BayScribe: Savings and Control
Records One
BayScribe is a Clinical Documentation System that is provided to healthcare facilities as a service – Software as a Service – relieving facilities of the financial burden to purchase expensive hardware to support Clinical Documentation. There are three key areas of benefit to the facility: Cost, Control and Performance. The focus of this White Paper is Cost and Control and the areas of ...

Clinical Documentation Systems Video

Henry Schein MicroMD Corp Video Henry Schein MicroMD View how Henry Schein MicroMD builds it simple yet powerful Practice Management (PM) + Electronic Medical Records (EMR) software and automation tools with ...
Clinical Documentation's role in the pursuit of Meaningful Use BayScribe - Provides an overview on how Clinical Documentation Systems can positively impact the adoption of EHR technology ...
Clinical Documentation Systems CCI - Computer Credit, Inc Products

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