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

CAPD360 Insight

HITEKS is the Only Embedded Epic EHR Editor Focused on Improving Documentation Quality, Clinical time efficiency, and Reimbursement

CAPD360 Insight

CAPD360 Insight For NoteReader CDI is a real-time Physician Workflow solution which provides immediate feedback to the physician and/or CDI Specialist based on tested algorithms with high positive predictive value (i.e. we don’t annoy users with many false positive queries). CAPD360 Insight For NoteReader Physician Workflow is fully integrated into Epic’s CDI workflow and reporting environment, and is the only solution which contractually requires Epic to prioritize enhancement requests through the App Orchard.

CAPD360 Insight For NoteReader CDI is part of HITEKS’ Insight Real-time Intelligence suite of products. HITEKS supports the most advanced designer tools which allow our clients to control 100% of the Physician Workflow Query rules, and create custom libraries of Physician Workflow Queries.CAPD360 Insight.

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CAPD360 Insight For NoteReader Physician Workflow has the following advantages differentiating it from back-end CDI Workflow tools:

Instead of having to rely on untimely HIM feedback from manual coding review and back-end HIM systems, CDI Specialists now have a complete clinical workflow system available to them through HITEKS’ Insight powering CAPD360 Insight For NoteReader CDI. Local rules and HITEKS’ expansive library of over 100 automated query areas at their fingertips help CDI specialists identify query opportunities as soon as physicians complete their visit note. This includes the following up-to-date insurance-specific information, which is based on HITEKS’ experience and proprietary reference knowledge of millions of rules:

– Pediatric CDI
– CPT/HCPCS
– NCCI Edits
– ICD Rules
– PQRS Rules
– MIPS Rules
– Specialty Bundling
– A.I. Insight RecognitionTM

10x faster than any other NLP services currently on the market, HITEKS’ CAPD360 Insight For NoteReader CDI takes advantage of modern software architecture guided by a management team of physicians. Competitors’ system response times support only “Silent Mode” because they are not timely or accurate enough for Direct Mode, reducing the compliance advantage of immediate queries. With HITEKS’, CDI Specialists have a true clinical, front-end tool which interacts with the EHR workflows so that CDI Specialists are in control. Other solutions rely on antiquated, back-end workflow and logic which cannot integrate with the EHR front-end system. After testing automated queries in Silent Mode workflow, CDI Specialists can decide to move some query types to Direct Mode where providers are notified that they will receive certain queries as CAPD (Computer-Assisted Physician Documentation) without manual review.

Which is more than competitor solutions CAPD360 Insight For NoteReader CDI utilizes a library of diagnosis modifiers and has built in medical necessity knowledge, which identifies incomplete clinical terms and suggests possible specificity during documentation. It also identifies areas that lack appropriate justification for a reimbursable diagnosis or procedure, and symptom combinations which require a stated diagnosis. This leads to fewer false positives and false negatives, as well as less alert fatigue.

HITEKS is the only vendor to offer a CDI solution with execution in Direct and Silent modes.

–Direct Mode: Provides immediate (<2 seconds) response time to physicians who are in the process of completing a note. This enhances claims coding capacity and compliance while reducing time spent on revenue cycle. Direct Mode in the EHR allows providers to significantly reduce the amount of time spent on returning to their patient’s chart to manually review CDI Queries.

– Silent Mode: Provides immediate queries to CDI and HIM Specialists with query names and prioritized numbering, which is especially useful for chart review to validate the Evidence for queries and also for determining Direct Mode candidate query types.

This ensures the protection of all patient health information (PHI). Unlike legacy vendors who use Microsoft platforms, HITEKS leverages more secure Linux systems with encrypted (VPN) tunnels for HL7 and web services data exchange between HITEKS and the Epic client EHR system.

HITEKS’ designer tool includes a “User Customization Menu” which allows HITEKS users (either directly or indirectly through HITEKS support) to add their own local terms or abbreviations for their clinical specialization by searching through SNOMED terminology in the Terms section. CAPD360 Insight is deployed as a service API for Physician Workflow Designer, which allows client personalization through custom GUI configuration without having to use “Silent Mode”. HITEKS also has a default configuration with a vast query library of over 100 Pediatrics and Adult queries that can be used out-of-the-box.
HITEKS not only leads the Physician Workflow Industry with the most number of diagnoses areas for automated Physician Workflow review, but we also lead in Pediatrics due to our ability to use Age, Gender and other Demographics along with our clinical expertise from Pediatricians, Pediatric Nursing, Pediatric CDI and Pediatric Coding. Click below to learn about our approach to support Pediatrics Physician Workflow for Pediatric Clinics, Children’s Hospitals and Pediatrics wings and floors.

The impact of CAPD360 Insight For NoteReader Physician Workflow is faster query generation by CDI Specialists, faster chart review, higher compliance for physician responses, and direct querying to physicians for those query types which are shown to have high accuracy. Inpatient and ambulatory queries become more targeted, with summarized evidence to speed the response by physicians. 

CAPD360 Insight For NoteReader Physician Workflow in Epic 2018 and later versions powers simultaneous Direct and Silent Modes to automate and prioritizes real-time review by Physician Workflow Specialists of clinical documentation and structured data (labs, meds, vitals) for documentation deficiencies. HITEKS powers clinical and administrative workflows with our Artificial Intelligence algorithms and patient-specific NLP Technology to improve the efficiency of the health care enterprise revenue cycle in the following ways:

  • Improved accuracy of clinical complexity diagnoses in clinical documentation.
  • Better communication through patient-specific, instantaneous and evidence-based queries (Fewer False Positives & Negatives).
  • Significantly less chart review and evidence justification for queries.
  • Streamlined ICD-10 coding for accurate CMI and HCC diagnosis capture and reporting.
  • Improved medical necessity documentation for procedures.
  • Enhanced Physician Workflow integrity for increased Case Mix Index (Inpatient) and Risk Adjustment Factor (RAF) Scores (Ambulatory).
  • Simplified Direct Queries to Physicians to boost query compliance.