Computer-Assisted Physician Documentation
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.
Physician Workflow with CAPD360
Epic-Integrated Tools
Embedded Note Editor & Care Team Queries
Provider gets prompt in the EHR
Concurrent Documentation
(while they are documenting)
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
Provider gets inbox query
Border between Concurrent & Retrospective
Named Provider will get an inbox query
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
Manual Query Process
Post-hoc documentation
Query sent to Provider's Inbox
Diagnosis added to the addendum form
- Greater Payer Denials
- Lost Physician Time
- Captures Missed Cases
3x Greater Physician Response to Queries before Discharge
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
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
Realize the Power of Concurrent, Proactive CDI
Embedded Editor
Care Team Mode
Embedded, Direct & Silent Modes
• Embedded Direct Mode
• Care Team Direct Mode
• Impact on Query Burden
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 |
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
PowerBI Reporting Dashboard: Response Summary
PowerBI Reporting Dashboard:
User Responses
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.