How a New York state hospital improved operative notes to boost payment — 4 takeaways

No physician relishes time spent typing up postoperative reports. Using voice recognition technology to dictate reports in the operating room presents a breakthrough that can save time, improve accuracy and ease surgeons' administrative burden.

During a June webinar hosted by Becker's Hospital Review and sponsored by Nuance, a leading surgeon joined a Nuance executive to explain how using this technology improves physicians' satisfaction and collections. Panelists were: 

  • Greg Holland, director of solutions marketing, CAPD, Nuance
  • Rick Weinstein, MD, orthopedic surgeon at White Plains Hospital (N.Y.), director of Westchester Sport & Spine, medical director for the International Boxing Federation (IBF)

Four key takeaways were: 

  1. Computer-assisted physician documentation utilizes voice recognition and machine learning to streamline the physician's workflow. Solutions powered by artificial intelligence can improve workflow and documentation for physicians. Nuance offers an array of enterprise solutions. "The more data points that are available, more context and little bits of information that can be pulled together to learn subtleties around speech patterns," the more improvement in the machine learning and speech recognition for its healthcare segment, Mr. Holland said. Physician workflows are integrated into other systems, including EHRs.

  2. When creating operative reports with CAPD, surgeons save time and improve efficiency and accuracy. Nuance's solution allows surgeons to create operative reports using voice recognition software, in real time instead of after the fact. The surgeon is then able to move directly to the next procedure or spend additional time with patients. "The most important asset that any doctor or hospital has is time, and we don't want to waste time," Dr. Weinstein said. In comparison to the old practice of dictating reports that had to be sent out for transcription, or even more recent manual typing of reports after a procedure or at the end of the day, seamless dictation with voice recognition saves time and money. The reports are immediately accessible from any computer. In postoperative appointments at the office, surgeons can rely on them to refresh their recollections of procedures. They can easily provide them to the patients, who can then share them with physical therapists who better understand what was done.

    Building templates for specific, frequently replicated procedures, such as those in orthopedic surgery, offers several benefits. It is efficient for the surgeon and improves accuracy, reminding the surgeon of necessary elements or specific language required by insurers. Templates are customizable to capture specifics of the patient's anatomy or pathology, but the burden on the phsyician for each new operative report is minimized.

  3. Simplifying report preparation can support clinician well-being. Physicians don't welcome spending time on reports. "We weren't trained as typists. We weren't trained to write notes," Dr. Weinstein said.

    Nuance helps surgeons get started with a system solely designed for operative reports. "We had a whole team of people supporting us, actually in the operating room while we're dictating notes. And it made the process much simpler," Dr. Weinstein said.

  4. Implementing solutions for CAPD improves the insurance payment process. Nuance's solution reduces the risk of hurdles in obtaining payment for services from insurance providers. The documentation is available more quickly for the billing department. The use of templates reminds surgeons to include necessary language. Nuance technology populates insurance codes automatically, at the time of the procedure, which the surgeon can review and modify if necessary. These features all save time, promote efficiency and improve accuracy. Dr. Weinstein noted that using Nuance, requests from the billing department concerning appeals for codes that were not paid have "significantly dropped, because my documentation was improved."

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