Computer-Assisted Physician Documentation
From 3M and Nuance
Computer-Assisted Physician Documentation (CAPD) will support physicians through the entire clinical documentation process, providing instant access to information needed to capture the complete patient encounter. As part of the CAPD workflow, clinicians will be able to use speech-recognized dictation to document in their own words, preserving the unique patient story while also incorporating relevant structured data.
One of the components of CAPD is Clinical Language Understanding (CLU), a sophisticated software technology able to parse clinical notes and capture key clinical findings in them, such as diagnoses, medications, allergies, vital signs or social history items. These are then standardized from narrative expressions into ICD-10 codes in a fully compliant and predictable way by the software.
The other component is Clinical Documentation Improvement (CDI) a technology which utilizes detailed knowledge of the ICD-10 coding system to identify if more information is needed to assign the most accurate code. The power of these two technologies combined provides a solution that will, in real time, translate the physician’s voice into text, analyze it to identify gaps and ambiguities that could affect coding accuracy, and immediately provide targeted feedback to the physician for incorporation into his notes.
CAPD will automatically detect missing information, unclear associations between relevant findings, or unspecified diagnoses, and then highlights them for physician consideration and correction. Consider, for example, a patient who is admitted to the emergency room with a serious episode of asthma. A busy emergency doctor would typically dictate “acute asthma exacerbation” as the reason for admission. ICD-9 has only one code for this diagnosis. ICD-10, however, has three possible codes, based on the gravity of the asthma episode (mild, moderate or severe). Additional information is needed to determine which ICD-10 code is more clinically useful. CAPD asks the physician—while dictating—to add the severity attribute by dictating the additional text or simply accepting one of the suggestions the system will provide.
CAPD will help generate sufficient detail for both ICD-9 and ICD-10 coding, and promote documentation accuracy to reduce audit risk and support regulatory compliance. The streamlined process is designed to reduce documentation inquiries from coders and CDI staff, bringing greater efficiencies to clinical workflow so physicians can focus on patient care.
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For more information about Computer-Assisted Physician Documentation, go to www.together-we-will.com or read the White Paper.
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