The Impact of Electronic Health Record in Clinical Documentation Improvement: Literature Review

Digital transformation in the healthcare has brought various opportunities. Various studies have indicated the different aspects of social determinants of health initiatives as well as their impacts on the outcome. It is noticed that the healthcare delivery phenomenon is changing due to electronic health records that is integrated into clinical documentation to improve processes. This study focuses on both side of the aspect, which are the challenges as well as the opportunities that result from this union. The merging of Digital Medical Records (EMR) into Medical Documentation Improvement (MDI) practices represents a pivotal change in the landscape of healthcare provision. This complex transformation holds both difficulties and opportunities emerging from this integration, drawing insights from diverse academic works. The adoption of EMRs harbors tremendous potential for streamlining clinical workflows, boosting care coordination, and enhancing productivity across healthcare systems. However, this transition also presents challenges ensuring user proficiency and training in EMR documentation emerges as one primary hurdle. Interoperability among providers and institutions also surfaces as a critical challenge in merging EMRs with MDI practices. The advancement of the EHRs into the digital field brings cyber security threats such as data breaches and confidentiality violations to the forefront. It is noticed that integration of EHRs with CDI routines presents hurdles as well as opportunities for healthcare institutions. The obstacles can be addressed through extensive preparation, connectivity initiatives, security measures, and streamlined documentation is pivotal. However, capitalizing on prospects for progress and innovation, such as integrating decision support tools, leveraging cutting-edge technologies, and collaborative efforts between stakeholders, can optimize CDI effectiveness and ultimately enhance patient care delivery.