5 takeaways to better understand CAPD documentation

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There are computer products that optimize workflows for coders and clinical documentation specialists. New computer-assisted physician documentation systems leverage artificial intelligence and machine learning to support physicians, who play a key role in the documentation process.

During a Cerner-sponsored session at Becker's 6th Annual Health IT + Revenue Cycle Conference, Heidi Zimmerman, BSN, RN, director for Cerner Intelligence, defined CAPD, explained how it works and discussed how CAPD technology optimizes care documentation and revenue cycle management.

Five takeaways:

1. CAPD solutions help physicians ensure accurate documentation. Ms. Zimmerman defined computer-assisted physician documentation as solutions that utilize advanced technologies to help physicians ensure their documentation accurately and consistently reflects the care being provided and presents information to physicians at the point of care.

Ms. Zimmerman defined computer-assisted physician documentation as solutions utilizing advanced technologies to help physicians ensure their documentation reflects accurately the care being provided and presents information to physicians at the point of care.

CAPD uses natural language processing to read and convert unstructured documentation from a patient's EHR into structured information. Once data is structured, condition-specific algorithms determine inclusion and exclusion criteria for presenting information to the physician.

2. Three use cases show how CAPD improves documentation and patient care. Zimmerman illustrated CAPD through these use cases:

    1. Identifying a missing diagnosis, where NLP finds clinical evidence for a diagnosis that hasn't been documented and presents this information to the physician.
    2. Adding specificity to an unspecified diagnosis, where a physician indicates a diagnosis but lacks specificity. The system presents findings to the physician indicating a more specific diagnosis.
    3. Validating a documented diagnosis, which occurs when a physician has documented a diagnosis, but the system didn't find evidence to support this diagnosis. The system notifies the physician so they can make necessary changes to the documentation.

Importantly, the software displays documentation improvement "nudges" along with the relevant clinical evidence from the patient's chart.

3. CAPD makes life easier for physicians but doesn't replace documentation specialists. CAPD reduces physicians' cognitive load while "helping ensure accurate and complete documentation," Ms. Zimmerman said.

"Information is presented to the provider within their workflow, making it a natural part of the chart review process and supporting actions they can quickly take to update their documentation," Ms. Zimmerman said. "By having access to this information . . . the physician doesn't have to dig through the clinical record, which reduces clicks and time spent looking for information. Isn't this what the EHR has always promised to do for clinicians?"

While easing life for physicians, CAPD "is designed to complement the role of the clinical documentation specialist," Ms. Zimmerman said, not replace it.

4. Cerner's CAPD solution was developed using principles to avoid "leading" providers. "When we started on this CAPD journey, one of our overarching goals was to ensure we are applying AI responsibly to documentation and coding," Ms. Zimmerman explained. To apply AI responsibly, Cerner developed principles which include content transparency, ensuring decision-making is always up to the physician and workflow integration. "There should be transparency to the algorithms that define each condition, so clinicians fully understand what is being presented as a documentation opportunity and why." Showing the criteria used by CAPD's underlying AI algorithms — a broader concept known as "explainable AI" — aims to avoid "leading" physicians to automatically accept a suggestion.

5. From an organization perspective, CAPD solutions mitigate risk and facilitate revenue cycle management. The focus of Cerner's solutions on diagnosis accuracy helps not only avoid patient harm, but also mitigate risk from an auditing and compliance perspective, thus reducing potential penalties. And by ensuring that the care provided is appropriately captured, they streamline reimbursement and decrease the chance of denied insurance claims.

To learn more about the event, click here.

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