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
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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 |
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Compliant Query Practices* Followed by HITEKS
- All queries are memorialized
- Query titles and suggestions are not leading.
- Query formats follow the Guidelines.
- Provider queries include relevant clinical indicator(s).
- Undocumented diagnoses are not specifically suggested.
- Choices provided as part of the query reflect patient-specific conclusions.
- Prior information from other encounters is limited.
- Links are provided to access the clinical indicators.
- 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
- 40-70% Proactive query Satisfaction to reduce Denials, create CDI Efficiency.
- Extensive, Customizable Query Library for Revenue and Quality Sensitive Diagnoses.
- Compliant and Scalable.
- Embedded in Provider Workflow in Epic.
- Efficient Implementation, No Additional Software or Hardware.