Clintegrity Computer Assisted Physician Documentation

Put smart technology to work

Automated, clinically appropriate guidance and clarifications

Clintegrity CAPD is a Computer Assisted Physician Documentation technology designed to help physicians include details necessary to reflect an accurate picture of the severity of each patient in their care. With revolutionary Clinical Language Understanding (CLU) technology and over 20 years of innovation driving Clinical Documentation Improvement (CDI) success, Nuance Healthcare solutions combined with the JA Thomas Compliant Documentation Management Program® strategies go beyond just using documentation to support coding. Automated, clinically appropriate guidance and clarifications are presented to physicians at natural points during their workflow. As an automated extension to your CDI program this combined solution helps physicians document the details required for communication of care, reimbursement and quality reporting in their preferred workflow. Utilizing the power of Clinical Language Understanding (CLU) to analyze and understand the content of a dictated note in "real time" allows Clintegrity CAPD solutions to identify gaps and ambiguities in the note and give the physician pertinent and focused suggestions to improve clinical documentation. Automating the CDI process in such as way engages physicians at the point at which they are documenting care and focusing on communication about the patient, enabling them to more efficiently indicate details relevant to ongoing patient care and communication with other care givers. Clinical Documentation Improvement Specialist teams are able to review the automated interaction with the physician allowing them to focus their efforts on more complex cases and continued quality improvement initiatives.

Clintegrity CDI solutions position your organization for success, meeting the challenges of ICD-10, Value Based Purchasing and other Quality reporting needs and delivers the right outcomes for your patients, your clinicians, your organization, and your bottom line.


Put smart technology to work

Clintegrity CAPD is an automated interactive system that will help physicians increase accuracy and completeness in their documentation and ensure reimbursement better reflects the level of care provided. To help improve physician adoption and engagement, Nuance makes CAPD solutions available to Electronic Health Record vendors to integrate into physician documentation workflow. By bringing the clarification process closer to the documentation process physicians are able to address missing details while still focused on documenting the patient’s treatment and care. CAPD enables physicians to continue using narrative — their preferred mode of documentation — in addition to structured data entry through advancements in speech recognition and Clinical Language Understanding technology. This optimal combination of speech and understanding technology offers the necessary balance in clinical documentation to communicate the essence of what’s happening with each patient while still addressing organizational needs for discrete data elements and details to support reporting requirements.

Ultimately, Clintegrity CAPD allows your organization to put smart technology to work to help improve physician documentation processes that ensure appropriate reimbursement, more accurate quality reporting, and support documentation needs in ICD-10.


How Nuance makes a difference

  • Helps physicians improve clinical documentation to ensure diagnoses accurately reflect the clinical condition of the patient, improving communication between caregivers
  • Better documentation ensures accuracy of your records, substantiates claims, mitigates risk and more accurate reimbursement
  • Facilitates and streamlines documenting in ICD-10 for physicians and staff through automated technology
  • Brings the clarification process closer to physician documentation workflow and clinical thought process
  • A clinically focused approach to documentation improvement improves the ability to manage population health and function successfully in an ACO and shared payment models
  • Allows Clinical Documentation Improvement teams to focus on more complicated cases and quality improvement efforts

Clintegrity CAPD is an automated interactive system that will help physicians increase accuracy and completeness in their documentation and ensure reimbursement better reflects the level of care provided. By bringing the clarification process closer to the documentation workflow physicians are able to address missing details while still focused on documenting the patient’s treatment and care. Clintegrity CAPD enables physicians to continue using narrative — their preferred mode of documentation — in addition to structured data entry through advancements in speech recognition and Clinical Language Understanding technology. This optimal combination of speech and understanding technology offers the necessary balance in clinical documentation to communicate the essence of what’s happening with each patient while still addressing organizational needs for discrete data elements and details to support reporting requirements.

Ultimately, Computer Assisted Physician Documentation allows your organization to put smart technology to work to help improve physician documentation processes that ensure more accurate capture of patient severity and acuity, which leads to appropriate reimbursement.


Workflow

Capturing all diagnoses makes it possible to set the principal diagnosis correctly at the beginning of the patient’s stay, and helps to ensure that appropriate treatment and care shorten the overall length of stay, guide post discharge care and reduce potential readmission. The severity of illness and risk of mortality will be accurately documented and proper details will be available for coding either manually or using Computer Assisted Coding for the correct DRG assignment.

Additionally, benefits of documented secondary diagnoses include:

  • Accurate mortality index, observed and expected mortality stats (O/E)
  • Appropriate severity of illness (SOI) for public report cards
  • Accurate APR-DRG Severity of Illness and Risk of Mortality
  • Favorable preparation for ICD-10

Clintegrity CAPD automatically reviews all physician documentation for a patient’s stay, looking at the patient’s story in its entirety, and asking physicians for more information only when necessary. As physicians become more specific in their documentation, the number of clarifications will naturally reduce. Clarification response and agreement rates are maintained in a comprehensive audit trail, allowing for evaluation and continuous improvement of clinical documentation improvement processes. Automated review means every document, for every patient, is evaluated with the same level of consistency and high quality, leveraging the latest published guidelines, which are automatically updated on a regular basis. This helps to immediately increase the coverage of concurrent documentation review programs without the need to increase staff.

Ultimately, Computer Assisted Physician Documentation allows your organization to put smart technology to work to help improve physician documentation processes that ensure appropriate reimbursement, more accurate quality reporting, and support the transition to ICD-10.

Make Advanced Practice CDI your key to success

A clinically focused documentation improvement strategy will ensure your physicians have the tools and guidance they need to approach the challenging new face of documentation requirements with confidence. Clintegrity CAPD and Clintegrity CDI offer both the technology and clinical guidance necessary to help you work smarter to keep up with ever changing demands of clinical documentation. We provide the tools, education and best practices to ensure your success.

Point-of-entry program

The best way to get the record straight - right from the start

As more and more patients are admitted through your Emergency Department, accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected by under-documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.

Nuance has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.

The solution: Clintegrity CDI Point of Entry Program

Because documentation of critical information starts in the Emergency Department, the Point of Entry program starts there too - evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or inpatient), ensuring compliance with quality core measures, creating a problem list at the point of entry, and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity CDI; and takes it even further, providing comprehensive clinical integration management.

New role: Clinical Integration Specialist

With this new solution comes a new clinical role - the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.

Your CIS is trained to:
  • Perform hands-on patient assessments
  • Identify and secure documentation of POA conditions
  • Assist with quality indicators such as core measures and patient safety indicators
  • Establish a problem list at the point of entry
  • Facilitate accurate, compliant clinical documentation by providing concurrent support to physicians
  • Review medical records for completeness and accuracy
  • Maintain liaison with ED and inpatient case manager and CDS
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