Computer-Assisted Physician Documentation Research

Part
01
of one
Part
01

Computer-Assisted Physician Documentation Research

Key Takeaways

  • The 3M M*Modal computer-assisted physician documentation (CAPD) enables physicians to proactively address common documentation deficiencies and specific queries.
  • CAPD solutions prevent revenue loss and reduce compliance risks within health systems. The CAPD technology ensures that physicians support the best practices to front-end workflows in real-time by "getting it right the first time."
  • Rush University Medical Center implemented HITEKS’ AdvocateMD Powering NoteReader to automatically speed up the delivery of CDI and queries to physicians without slowing down the doctor's workflow.

Introduction

  • This research discusses existing literature/studies supporting the use of Computer-Assisted Physician Documentation (CAPD) for CDI (Clinical Documentation Improvement), including real-time queries and decision support alerts. For each piece of literature/study included, we have provided a link to the literature/study, a detailed description (as available), and supportive data points from the literature/study. Selected literature/studies showed that when physicians receive more timely advice (or queries or alerts), they act on it instead of the delivery of advice retrospectively.
  • We have also provided financial and workflow metrics of CAPD technology gathered from four HITEKS' customers and detailed any financial/workflow improvements after implementing the CAPD technology.

Existing Literature/Studies Supporting the use of Computer-assisted Physician Documentation (CAPD) for CDI (Clinical Documentation Improvement)

Driving value with 3M™ M*Modal Computer-Assisted Physician Documentation (CAPD)

  • The 3M M*Modal computer-assisted physician documentation (CAPD) enables physicians to proactively address common documentation deficiencies and specific queries.
  • Some ways in which the 3M M*Modal CDI Engage One utilizing CAPD benefits physicians include creating time to care by unifying clinical workflows, improving the quality of documentation at the time of note creation, promoting an information-driven, consistent and reliable approach to physician documentation, significantly boosting physician productivity, efficiency, and satisfaction, facilitating improved clinical communication, and minimizing retrospective queries."

Nuance and Epic Collaborate to Deliver Computer-Assisted Physician Documentation

  • Nuance Communications, Inc. and Epic partnered to deliver the Epic NoteReader CDI solution.
  • The Epic NoteReader CDI solution provides real-time clinical documentation improvement (CDI) feedback to physicians at the point of care, identifies clinical indicators in a patient's medical record, and alerts the physician in real-time on any missing information that needs clarifications, describes the quality of care provided, and reduce retrospective coding queries.

10 Things to Know: Driving Surgeon Satisfaction With Computer-Assisted Physician Documentation (CAPD)

How AI Supports Physicians and Improves Clinical Documentation Integrity

  • CAPD solutions deliver proactive approaches to physicians within their normal workflow to close gaps in patient care and the clinical note.
  • CAPD solutions prevent revenue loss and reduce compliance risks within health systems. The CAPD technology ensures that physicians support the best practices to front-end workflows in real-time by "getting it right the first time."

Hospital Uses Natural Language Processing for Assisted Physician Documentation

  • Nuance’s healthcare NLP solution utilizing CAPD is powered by Dragon Medical One, Nuance’s healthcare AI system.
  • This solution enables physicians to retrieve the history of past illnesses, provide real-time intelligence by automatically issuing clarification during documentation, identify clinical evidence that supports a more specific diagnosis, and dictate progress notes.

Nuance Introduces Dragon Medical Advisor, Computer-Assisted Physician Documentation (CAPD) for ICD-10

  • The Dragon Medical Advisor solution utilizing CAPD automatically provides real-time feedback to physicians while documenting patient encounters instead of fixing records for patients met hours or days before.

Financial and Workflow Metrics of CAPD Technology Gathered From the HITEKS' Clients

Timeliness of Care

  • Rush University Medical Center implemented HITEKS’ AdvocateMD Powering NoteReader to automatically speed up the delivery of CDI and queries to physicians without slowing down the doctor's workflow.

Services Efficiency

  • Prime Healthcare implemented HITEKS' real-time sepsis surveillance to improve the facility's real-time active sepsis surveillance. The surveillance used natural language processing to "find infection sources, and artificial intelligence software to identify lab results and vital signs from real-time data feeds from the EHR system." The facility expects over a 90% reliance on this HITEKS' technology.
  • Rush University Medical Center implemented HITEKS' CAPD360 insight for Epic’s NoteReader Clinical Documentation Improvement (CDI) to enhance physician and CDI and quality workflow. CAPD360 insight enables physicians to receive feedback on diagnoses that require better documentation. The institution was expected to have over 50% reduction in overall queries.
  • Hackensack Meridian Health implemented HITEKS’ real-time physician insight technology to optimize diagnoses and quality care. The Epic’s NoteReader prompts physicians to add suggested diagnoses and dedications directly from a physician’s notes. HITEKS’ insight technology integrates with Electronic Health Record (EHR) clinical notes' workflow to suggest the new and more specific diagnosis in physician documentation in real-time and enhance workflow.

Profitability

  • The CAPD360 Insight For NoteReader CDI real-time intelligence technology at the University Medical Center of Nevada provides automated support that reduces a physician's time to access relevant patients' data. This solution makes it possible for the medical center to receive valuable feedback on "both implicit and explicitly-stated diagnoses which require attention due to either documentation integrity issues or quality concerns from worsening patient conditions." The timely feedback improves data capture and documentation, which reduces the revenue cycle time to submit claims. Therefore, HITEK can significantly reduce the cost of its solutions to boost its customer returns on investments.

Research Strategy

We leveraged the most recent and reputable sources of information available in the public domain, including institutions' official websites, Becker's Hospital Review, Emerj, and Business Wire, among others. However, information on financial/workflow improvements after using CAPD technology was low in the public domain.
Next, to identify at least 4-7, we scoured through the HITEKS' press releases and blogs to identify some of its clients.
Sources
Sources