Future of Clinical Documentation and Data Capture

Much of what is currently documented in the electronic health record is in response to increasingly complex and prescriptive medico-legal, reimbursement, and regulatory requirements. These requirements often result in redundant data collection and cumbersome documentation processes. This Webinar will examine the clinical, socio-technical, and policy-related trends that are shaping the future state of clinical data capture and documentation. The presenter will argue that the main purpose of documentation should be to support patient care and improved outcomes for individuals and populations, and that documentation for other purposes should be generated as a byproduct of care delivery.

Learning Objectives

During this webinar, participants will learn about:

• The evolution and multiple uses of clinical records
• The policy recommendations and research priorities identified in AMIA's 2011 Health Policy Meeting discussing the future state of clinical data capture and documentation

• Barriers and facilitators in the transition from paper to electronic documentation

Speaker Information

David Vawdrey is Assistant Professor in the Department of Biomedical Informatics at Columbia University in New York City. He studied Biomedical Informatics at the University of Utah, designing and evaluating novel strategies for medical device data acquisition in the intensive care unit. His research interests include electronic documentation, using information technology to support clinical collaboration and handoffs in care, and enhancing patient engagement. In addition to his research pursuits, Dr. Vawdrey is Assistant Director of Informatics Services for NewYork-Presbyterian Hospital, where he guides custom application development within the hospital’s commercial electronic health record.