From the May 2011 issue of HealthCare Business News magazine
Similarly, computer-assisted coding enhances productivity and workflow of medical coders. Incidentally, many industry analysts view CAC as a key tool for helping medical coders transition to ICD-10 coding.
Physician documentation is one of the next obvious frontiers for computer-assisted enhancements, especially in light of the impending transition. With optimally designed systems, physicians can document more efficiently and completely without having to jeopardize quality or be disrupted with information queries.
Computer-assisted physician documentation, or CAPD, must be able to accept physician documentation, which is overwhelmingly spoken narrative, without dramatically altering the physicians’ workflow.
In order to be successful, CAPD will need to be able to understand clinical narrative and leverage an extensive and up-to-date knowledge base of CDI guidelines and coding requirements.
Conceptually, the system should function similarly to a very sophisticated spelling or grammar-checker, continuously monitoring physicians’ documentation and, when necessary, prompting for clarification or additional information.
CAPD systems could revolutionize documentation and coding, holding the promise of reducing the burden of the ICD-10 transition on physicians and staff. However, a number of significant challenges must be addressed before CAPD could become a reality and be adopted into routine use by physicians.
Like other computer-assisted platforms, if not designed correctly, CAPD could lead to alert fatigue, which could result in physicians overlooking or ignoring the automated prompts or feedback. Therefore, CAPD must be designed to prompt for additional information only when it is absolutely necessary. It must intelligently analyze the entire content of the patient medical record to find clues before unnecessarily prompting for information already available in other parts of the document. Furthermore, CAPD must learn from experience and customize performance to the unique styles and habits of individual users.
While the concept is very intriguing and holds considerable promise, we must be careful not to position CAPD systems as the single solution for clinical documentation challenges. Rather, they should be viewed as an additional tool to enhance documentation and need to be considered in the context of an integrated and comprehensive CDI program. When used correctly, CAPD can support and sustain internal efforts to improve clinical documentation and to ensure appropriate reimbursement and more accurate quality reporting.
Isam Habboush is the director of product management at Nuance Communications, Inc.
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