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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 is an EHR agnostic cloud-based software service built on HITEKS’ Insight A.I. platform.  Within Epic, CAPD360 is the only solution powering the NoteReader CDI workflows which provide real-time, immediate Physician Workflow queries and notifications as feedback to the individual physician on their individual pre-saved/signed note in the Embedded Editor feature, and to the entire care team for queries based on signed documentation.  CDI Specialists have oversight of the process using Epic Work Queues and are able to control the logic, follow-up on queries which are read but not responded to or satisfied, as well as the activation/de-activation of queries.  

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CAPD360 is based on tested algorithms with high positive predictive value.  HITEKS has conducted numerous studies with its clients which have shown that CDI Queries do not need to be completely accurate if they are delivered in real-time at the point of care.  Rather, an acceptable error rate is preferred to ensure that the queries are received in real-time and which learn from physician and CDI feedback responses.  HITEKS uses the PowerBI Dashboard for Reporting and Analytics to continuously track queries and the user responses, and share these data with clients on a regular basis.

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

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
– 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 is a significantly reduced manual CDI query generation and over 3x higher compliance for physician responses to CDI queries before discharge. Direct querying to physicians within EHR workflow is an effective method to quickly resolve about half of all queries, and improve the Working DRG. Querying physicians in a reactive way or within a non-EHR workflow environment is detrimental to accurate, compliant and timely responses, and should be avoided or mitigated. Physician champions, Chief Medical Informatics Officers (CMIO) and other physician stakeholders should be included as decision-makers on the workflows and tools that are used for their point of care querying. Too often they are forgotten or suppressed, resulting in higher query burden with poorly designed workflows, to the detriment of the health system’s revenue cycle and quality metrics. HITEKS powers clinical and administrative workflows with our A.I. algorithms and patient-specific NLP Technology to improve the efficiency of the health care enterprise revenue cycle in the following ways:
  • Improved capture of both acute and chronic condition complexity in inpatient and outpatient clinical documentation.
  • Better communication through patient-specific, instantaneous and evidence-based queries in compliant format.
  • Enhanced Physician Workflow integrity for increased responses.