Building Best Practices for Telehealth Record Documentation in the COVID-19 Pandemic.

Telehealth services for patient visits have substantially surged during the COVID-19 pandemic. Thus, there is increased importance and demand for high-quality telehealth clinical documentation. However, little is known about how clinical data documentation is collected and the quality of data items included. This study aimed to identify the current state of and gaps in documentation and develop a best practice strategy for telehealth record documentation. Data were collected from January to February 2021 via a self-designed questionnaire for administrators and managers from physicians' offices and mental health facilities, resulting in 76 valid responses. Survey items included health organization demographic information, use of telehealth policies and procedures, and clinical documentation for telehealth patient visits. Findings from this study can be used to assist government, policymakers, and healthcare organizations in developing best practices in telehealth usage and clinical documentation improvement strategies.

Patient clinical documentation in telehealth environment: are we collecting appropriate and sufficient information for best practice?

BACKGROUND: During the COVID-19 pandemic, the use of telehealth for patient visits grew rapidly and served an important role as a valuable and necessary resource. Although clinical documentation is critical for telehealth patient visits, there is limited information about how healthcare facilities manage telehealth patient visit documentation, technology used for telehealth visits, and challenges encountered with telehealth patient visit documentation. This study aimed to assess the use of telehealth during the pandemic, the quality of clinical documentation in telehealth practice and to identify challenges and issues encountered with telehealth patient visits in order to develop a strategy for best practices for telehealth documentation and data management. METHODS: Data were collected for this cross-sectional study in January-February 2021 via a self-designed survey of administrators/managers from physicians' offices and mental health facilities. Survey questions included four categories: health organization demographic information; telehealth visits; clinical documentation for telehealth visit; and challenges and barriers related to telehealth documentation technology use. RESULTS: Of 76 respondents, more than half (62%) of the healthcare facilities started using telehealth for patient visits within one year of the onset of the COVID-19 pandemic, with 94% of respondents indicating an increased use of telehealth for patient visits since the pandemic. The most common types of telehealth patient care provided during the pandemic included pediatrics, primary care, cardiology, and women's health. The most consistent data documentation of telehealth visits included: date of service, patient identification number, communication methods, patient informed consent, diagnosis and impression, evaluation results, and recommendations. The telehealth visit data was most commonly used for patient care and clinical practice, billing and reimbursement, quality improvement and patient satisfaction, and administrative planning. The top barriers to telehealth use by the healthcare professionals included patient challenges with telehealth services, such as inequities in quality of technology, lack of patient understanding, and lack of patient satisfaction; this was followed by frustration with constant updates of telehealth guidelines and procedures, understanding required telehealth documentation for reimbursement purposes, payer denial for telehealth visits, and legal and risk issues. CONCLUSIONS: Findings from this study can assist government entities, policymakers, and healthcare organizations in developing and advocating best practices in telehealth usage and clinical documentation improvement strategies.

National Survey on Doctoral-Level Education in Health Information Management: Perceptions and Rationale.

Objective: The purpose of this survey was to understand the perceptions and educational goals of the health information management (HIM) workforce in regard to pursuing doctoral-level degrees. Method: Survey data were collected from members of the American Health Information Management Association (AHIMA) to gain further insight into their interest in pursuing a doctoral degree, their reasons for obtaining such a degree, their methods of learning, and their financial support for an advanced degree. Descriptive characteristics were collected from AHIMA profile information. Results: A total of 13,020 surveys were electronically sent to selected AHIMA members, of which 1,453 were returned, for an 11 percent response rate. Of the 651 respondents who indicated that they were interested in obtaining a doctoral-level degree, close to half would like to start their doctoral-level study in the next one to five years. Discussion: This research points to recommendations for efforts to increase student funding opportunities, to increase the number of accredited HIM schools/programs, to create opportunities for doctoral-level study in HIM, to offer options for blended online learning, and to increase the number of doctorally prepared and qualified HIM faculty.

Evolutionary trends in peer review.

The literature pertaining to the scientific peer-review process, which explains the history as well as the controversial debate over whether peer review truly enhances the quality of published studies, was reviewed. The strengths and weaknesses of peer review are summarized, and an overview of the possible future evolution of the practice is given. The studies that are included reflect a wide array of findings which both support and negate the practice. The implications are crucial for both authors and reviewers in the allied health sciences.