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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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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
Abdominal Pain Acute COPD/Asthma Hypomagnesemia
Abnormal CXR on Antibiotic Cor Pulmonale Hyponatremia
Acidosis Debridement Hypophosphatemia
Acute Blood Loss Diabete Mellitus Hyperglycemia Incision and drain
Acute Heart Failure Diabetic Hyperosmolarity Malignant Hypertension
Acute Hypercapnic Respiratory Failure Diabetic Ketoacidosis Nicotine Withdrawal
Acute Hypoxic Respiratory Failure Drug Overdose Pneumonia Specificity
Acute Myocardial Infarction DVT Pulmonary Embolism POA
Acute on Chronic Diastolic Heart Failure Dysphagia Phase Respiratory Failure
Acute on Chronic Systolic Heart Failure Elevated lactate with Sepsis (Severe Sepsis) Sepsis
Acute Respiratory Failure Elevated Troponin Sepsis with specific sources of infection
Acute tubular necrosis Fracture Shock
AIDS/HIV Gastroenteritis Simple Pneumonia
ARDS Hepatic Failure Severity SIRS
Asthma Severity HIV - Symptomatic/Asymptomatic Spinal Cord Edema
Acute Asthma/COPD Hypercalcemia Thiamine Deficiency
Atrial Fibrillation Hyperkalemia Thrombocytopenia
Bowel Obstruction Hypernatremia Uncontrolled diabetes
Child Abuse Hyperphosphatemia Urosepsis
Chronic Heart Failure Type Hypertension UTI
Coma Hypocalcemia UTI Linkage to catheter
Complex Pneumonia Hypokalemia

Elixhauser-Focused Queries
Anemia - Macrocytic Lymphoma
Anemia - Microcytic Malnutrition
Brain Hemorrhage Metabolic Encephalopathy
Cause of Delirium Midline Shift
Cerebral Edema Mild/Moderate Malnutrition
Chronic Kidney Disease Morbid Obesity >35+ & >40
CVA Obesity BMI>30
Cause of Delirium Pancytopenia
Drug induced hemorrhage disorder Portal Hypertension
Encephalopathy Pulmonary Embolism Specificity
End-Stage Renal Disease Pulmonary Hypertension
Fluid Overload Right Heart Failure Etiology
GI Bleeding + Ulcer Septic Encephalopathy
Hepatic Encephalopathy/Failure Severe Malnutrition
HFpEF with EF >=50% Solid Cancer
HFrEF with EF<50% Subdural Hemorrhage/Hematoma
Hypertensive Encephalopathy Toxic Encephalopathy
Hypothyroidism Uncontrolled diabetes
Immobility Status Underweight
Leukemia
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.