Medical Documentation Software, Clinical Documentation Improvement, CDI Clinical Documentation Improvement, CDI Program, Insight

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CAPD360 Insight For NoteReader CDI

Computer-Assisted Physician Documentation

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Present

  • Present queries as soon as possible while case details are still top of mind.

Remain

  • Remain completely in Epic so providers don’t need toggle between screens.

Allow

  • Allow query logic & workflow to be customized

Cover

  • Cover Revenue, Risk and Quality Sensitive Diagnoses.
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Physician Workflow with CAPD360

Epic-Integrated Tools

Embedded Note Editor & Care Team Queries

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Provider gets prompt in the EHR

Concurrent Documentation

(while they are documenting)

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Diagnosis In the Visit note

  • CAPD Direct Queries
  • Provider User Response Dashboards
  • CDI Validates Silent Mode Queries

CDI Moves unanswered CAPD360 Queries into Provider's Inbox

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Provider gets inbox query

Border between Concurrent & Retrospective

Named Provider will get an inbox query

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Diagnosis added to saved notes/ addendum

  • CDI removes any unanswered queries
  • CDI decides which queries to send to inbox

CDI Primary Query Development, Clinical Validation, 2nd Level Reviews

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Manual Query Process

Post-hoc documentation

Query sent to Provider's Inbox

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Diagnosis added to the addendum form

  • Greater Payer Denials
  • Lost Physician Time
  • Captures Missed Cases

3x Greater Physician Response to Queries before Discharge

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PRODUCT BENEFITS

#1 CAPD Configuration:
Provider Adoption & Query Compliance

#2 EHR Workflow Notifications:
40-70% Concurrent Queries Satisfied before Discharge

#3 CDI Workload Impact:
25% Efficiencies

#4 Revenue & Quality Impact:
3% Revenue increase Top 50 USNWR Scores

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Epic’s Gold Standard CDI Workflow App

Epic’s ONLY Embedded Note Editor within the EHR note screen

Complete provider documentation for quality rankings & compliant reimbursement

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Realize the Power of Concurrent, Proactive CDI

Embedded Editor

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Care Team Mode

care team mode

Embedded, Direct & Silent Modes

• Embedded Direct Mode

Presented to Individual Providers with notification under their Note (not via inbasket/email).

Uses Note side-bar: Query Title,  Suggestions & Evidence.

Reduce denials from changed documentation

Reduce overall query burden.

• Care Team Direct Mode

Presented to all Providers of Record for Signed Notes.

Uses Preferred Screens: Note Side-bar, 

To-Do List, Patient List

Increase responses by providers before discharge by 321%.

• Impact on Query Burden

Burden on individual physicians reduced

Answering Queries is intuitive and takes seconds

Note Editor Feature reduces denials, speeds final coding

Extensive Query Library

HCC, MS-DRG, MS-DRG Base, APR Base, APR S10/ROM lmpact
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Elixhauser-Focused Queries
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guidelines for achieving

Compliant Query Practices* Followed by HITEKS

  1. All queries are memorialized
  2. Query titles and suggestions are not leading.
  3. Query formats follow the Guidelines.
  4. Provider queries include relevant clinical indicator(s).
  5. Undocumented diagnoses are not specifically suggested.
  6. Choices provided as part of the query reflect patient-specific conclusions.
  7. Prior information from other encounters is limited.
  8. Links are provided to access the clinical indicators.
  9. Impact on reimbursement, payment methodology, quality. metrics or severity of illness are not indicated in the query process

* Based on AHIMA/ACDIS Compliant Clinical Documentation Integrity Technology Standards, 2022

PowerBI Reporting Dashboard:
Query Summary

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PowerBI Reporting Dashboard: Response Summary

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PowerBI Reporting Dashboard:
User Responses

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The HITEKS Difference

  1. 40-70% Proactive query Satisfaction to reduce Denials, create CDI Efficiency.
  2. Extensive, Customizable Query Library for Revenue and Quality Sensitive Diagnoses.
  3. Compliant and Scalable.
  4. Embedded in Provider Workflow in Epic.
  5. Efficient Implementation, No Additional Software or Hardware.