2011 Annual Health Policy Invitational Meeting

This event is by invitation only.

The Future State of Clinical Documentation and Data Capture

AMIA’s 2011 Annual Health Policy Conference considered the future of clinical data capture, content and documentation with its challenges and opportunities. Because of the importance of high quality clinical documentation and data in supporting patient care, and given current initiatives encouraging the adoption of electronic health records (EHRs), it is crucial to understand how documentation and data capture processes and policies may be affected by “going electronic.” Meeting participants articulated a vision for the “ideal” state of technology-enabled data capture and documentation. Discussions began by reviewing of a set of proposed principles to guide the future evolution of high quality data capture and documentation.

Participants considered the premise that while there are many legitimate uses of clinical data and documentation, priority needs to be given to capturing data and maintaining documentation that support patient care and enhance its safety, quality, effectiveness, and efficiency. Participants explored how the multiple roles of data and documentation present constraints that may compete with their primary purpose of supporting clinical work; how the different purposes are evolving over time in the face of advancing technology; and the role of policy in driving innovative change in the medical record that will yield improvements in both the data input and output spheres.

Meeting Materials

• Briefing Book
• Opening Session Slides
• Final Report

Panel Discussion: The Future is Here

• Jim Cimino
• Bethany Daily
• Hal Wolf

Suggested Background Reading

• Selected Resources. Policy Meeting Bibliography.
• Building a Collaborative Enterprise. Harvard Business Review
• Data Mining White Paper. Robert Wood Johnson Foundation
• High Confidence Medical Devices. Networking and Information Technology Research and Development Program
• Evaluation and Management Services Guide. Centers for Medicare and Medicaid Services
• Federal 2011 -2015 HIT Strategic Plan. Office of the National Coordinator
• Report to Congress National Quality Strategy. Department of Health and Human Services. March 2011

Sponsors