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Physician Documentation Improvement with Computer-Assisted Physician Documentation (CAPD)

Improve physician documentation.
Achieve unmatched outcomes.

Drive better data and outcomes across the continuum of care with Nuance’s full portfolio of computer-assisted physician documentation (CAPD) solutions, backed by artificial intelligence (AI) for healthcare.

Your strategic partner for delivering unmatched outcomes

The requirements of both value-based and fee-for-service reimbursement create immense pressure to deliver timely, accurate and compliant clinical documentation. This has contributed to a wave of burnout among clinicians and care teams, while creating significant downstream challenges for coders, clinical documentation improvement (CDI) and quality teams, among others.

Nuance’s unique approach to CDI, backed by artificial intelligence (AI) for healthcare and in-workflow clinical guidance, ensures that every patient receives an accurate clinical story. With a full portfolio of Nuance CAPD solutions that leverage AI and natural language processing (NLP), Nuance is the strategic development partner for leading EHRs with a unique approach that is widely embraced by clients.

Avoid rework so you can check up on your patients, not your documentation

Hospital staff burnout is fueled by documentation rework and retrospective queries and burnout leads to an exponential rise in medical errors, denials, and increased costs.

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Computer assisted solutions

Infographic: Computer-Assisted Solutions

Learn how you can avoid rework so you can check up on your patients, not your documentation.

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See Nuance CAPD at work

Physicians do not have to choose between quality time with patients and quality documentation. They can easily detail diagnoses, problems and procedures using Nuance next‑generation computer‑assisted physician documentation (CAPD) solution for quality and compliant documentation using real-time intelligence at the point of care.

Unmatched outcomes

Game-changing clinical and financial outcomes

Even with an active clinical documentation improvement (CDI) program, consistently achieving the type of improvements necessary for value-based care requires a new approach. Real-time intelligence, delivered at the point of care while the physician is documenting has more impact on patient care decisions than retrospective queries. Adding more CDI staff to broaden coverage may not be feasible, nor does it make sense in an ambulatory environment where the physician drives the documentation and coding process. In today’s value-based care environment, where clinical and financial outcomes are inextricably linked, in-workflow solutions with relevant in-context clinical guidance empowers physicians and CDS teams—delivering unmatched outcomes:

Improve clinical documentation at the point of care

  • Overall shift in capture of Severity of Illness (SOI) and Risk of Mortality (ROM) from Minor/Moderate to Major/Extreme
  • 36% improvement in capture of Extreme SOI
  • 24% improvement in capture of Extreme ROM
  • CAPD impact clarifications generated 1.2% CMI uplift across all admissions
  • $1,200 revenue improvement per clarified admission

Solutions

In-workflow advice and guidance for physicians and CDI teams

 

Nuance’s unique approach to computer-assisted physician documentation, backed by artificial intelligence (AI) for healthcare and in-workflow clinical guidance, ensures that every patient receives an accurate clinical story across the continuum of care. Our solutions help physicians and CDI teams by providing advice, clarifications and support at the right time.

Vincari Surgical CAPD

Connect with physician offices and hospital systems to provide access to daily surgery schedules and patient lists.

Learn more about Vincari Surgical CAPD

Dragon Medical Advisor
  • Diagnosis specificity advises physicians to add necessary details to communicate effectively across care teams and to assist the coding team with generating a timely and appropriate claim using AHIMA guidelines. For example, finding that diabetes mellitus has been documented without mention of the type or control, Nuance CAPD unobtrusively helps the physician add details while the patient story is fresh in their mind, helping them avoid the frustration of retrospective queries.
  • Clinical quality insights identify potential Patient Safety Indicators (PSIs) and Hospital-
    Acquired Conditions (HACs), prioritizing them so the physician can take immediate action. 
  • Risk adjustment factors understood in context support prioritized guidance for HEDIS, Star Ratings and other pay-for-performance measures in the ambulatory environment.  Correct documentation up front enables better capture of hierarchical condition categories (HCCs) to reflect the actual acuity of the patient population and enhances coding workflows to ensure appropriate value-based reimbursement.


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Vincari Surgical Computer-Assisted Physician Documentation
Vincari’s intelligent workflows bring together learned habits and existing patient information to streamline the clinical documentation and coding process. Surgeons are empowered to quickly create accurate and complete documentation that captures ICD-10 and Joint Commission compliant details. This in-workflow solution provides access to daily surgery schedules and patient lists and critical patient information from the medical record. It guides surgeons through the documentation process, automatically prompting them when clarifications are needed to capture the required level of specificity, to quickly and easily document the appropriate level of care.

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PowerScribe 360 Quality Checks
  • Medical imaging documentation checks bring real-time assistance to the radiologist by analyzing the full context of the exam order and report for quality errors, omissions and oversights such as laterality and gender inconsistencies that help radiologists ensure their reports are error-free. Just-in-time notification of critical results and actionable findings guide radiologists to document and send critical patient communications, which satisfy regulatory compliance and improve patient safety. 

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PowerScribe 360 Quality Guidance
  • Medical imaging clinical guidance provides quick and easy access to evidence-based clinical guidelines from leading sources—American College of Radiology (ACR), The Fleischner Society, American Joint Committee on Cancer (AJCC), American Association for the Surgery of Trauma (AAST), and Society of Radiologists in Ultrasound (SRU)—at the point of documentation.

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Embedded CAPD—available for Epic and Cerner

Discovery of additional diagnoses and comorbidities based on clinical evidence in the encounter helps clinicians better capture the true severity and acuity of each patient. For example, by identifying the signs and symptoms of sepsis even if it is not specifically stated in the note, Nuance CAPD can initiate a virtual clinical conversation with the physician to add critical details to the note that impacts the treatment and expected outcome for the patient.

Learn more about Epic NoteReader CDI with embedded Nuance CAPD

Learn more about Cerner Document Quality Review (DQR) with embedded Nuance CAPD

Embedded Fact Extraction—available for Epic and MEDITECH

Extraction of key clinical details locked inside physician narratives automatically structure unstructured data to reduce physician burden and help organizations drive more value in the EHR with relevant information mapped to industry-standard medical terminology. For example, automatically populating the patient problem, medication and allergy lists enhances EHR clinical decision-making. Extracting vital signs, procedures and social history fortifies quality reporting and compliance efforts without burdening physicians with additional tasks to satisfy regulatory requirements.

Learn more about Epic NoteReader with embedded Nuance Fact Extraction

Learn more about MEDITECH NLP Fact Finder with embedded Nuance Fact Extraction

Vincari Surgical CAPD

Vincari Surgical CAPD makes compliant clinical documentation and charge data is immediately available to various EHRs, care teams and coding departments, and to the provider’s office, eliminating the need to manually track charges. In less than 90 seconds, a highly detailed and compliant report is created and is immediately available in the EHR for the entire care team. In parallel, a copy is distributed to referring physician practices and an automated charge capture report, complete with suggested CPT and ICD-10 codes, is sent to the surgeon’s practice for coding and billing. The number of retrospective CDI and coding queries is reduced, as the necessary level of detail is immediately available to accelerate the revenue cycle and realize more appropriate reimbursement.

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When paired with Nuance CDI, these solutions provide teams fuller insights and access to a library of clinical strategies that support CDI teams, a worksheet approach for working up the DRG with integrated APR and MS DRG grouping, extensive clinical and coding reference materials, peer benchmarking, and outcomes analysis that incorporates financial and clinical quality analytics.

Learn more about Nuance CDI

Nuance Quality and Risk Adjustment

As care increasingly shifts toward an ambulatory setting, effective population health management strategies are becoming essential for success. With Nuance Quality and Risk Adjustment, physicians and coders can capture a broader picture of each patient’s chronic conditions, looking beyond the obvious to create a more coordinated, proactive, and compliant practice. In-workflow intelligence delivers context-aware, personalized clinical guidance at the point of decision making. This approach ultimately leads to better planning, treatment, and patient care, as well as appropriate reimbursement. Patient-focused, just-in-time intervention management enables:

  • Proactive targeting of chronic conditions with high-risk patient scheduling
  • Efficient presentation of opportunities to providers
  • Improved documentation of care
  • Enhanced communication between caregivers
  • Improved HCC capture rates
  • Greater accuracy of Risk Adjustment Factor (RAF) score

Learn more about Nuance Quality and Risk Adjustment

Building on decades of clinical expertise

Nuance’s AI heritage builds on decades of clinical expertise and experience with EHR workflow designed to improve physician engagement. Nuance trailblazed the development of CAPD with an emphasis on just-in-time guidance to support in-workflow processes during the physician’s clinical thought to drive a better experience and higher quality documentation as early as possible. Traditional CDI addresses documentation gaps with manual, retrospective record reviews and requests to physicians for more clinical detail. Nuance’s comprehensive portfolio of in-workflow CAPD solutions brings the right information to the right care provider at the point of decision making, reducing post-discharge and out-of-context queries and increasing physician satisfaction.

Nuance CAPD solutions are supported by opportunity assessment tools and services to monitor program performance and analyze physician activity. Our methodology helps clients target physicians who may need assistance transitioning to new documentation improvement standards and provides extensive practice with positive behavior modification during change.

In their own words: What customers are saying

Resources

Learn how Nuance CAPD, backed by artificial intelligence, can ease the clinical documentation burden for your care teams.

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