NLP to Enhance Your Hospital Documentation

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NLP to Enhance Your Hospital Documentation Though hospitals are required to demonstrate they can capture discrete data elements in an EHR to comply with meaningful use, they find it difficult to accomplish this when most of the information resides in the narrative portion of the medical record. Natural language processing or NLP handles this issue effectively and enhances hospital documentation. While speech recognition simply translates spoken words into digital, NLP deduces the meaning behind the spoken words.

There are several reasons for structured data to remain suboptimal in EHR such as EHR design, lack of lab interfaces and resistance of physicians in entering data into point and click templates. Many studies have proved that NLP can be used as an effective tool to unlock data from EHRs. With the capability to parse medical terms in a free text, this technology will speed up data entry and it will be easier to measure the performance of the electronic record system. However, the implementation of this technology in hospitals will change the role of medical transcriptionists. We will consider that after looking at the major advantages of NLP.

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www.medicaltranscriptionservicecompany.com Major Advantages



Aids EHR Content Completion – This technology can extract discrete elements from any data source, even unstructured sources and enter that information in the electronic record. A hospital that newly acquired an EHR can use NLP to identify problem lists from early patient narratives and transfer this information to the database. Without this technology, populating data fields in real time will require manual capture using point and click template, which may not be suitable in many clinical situations.



Effective Abstracting and Reporting – NLP is helpful for abstracting and reporting information for Physician Quality Reporting Initiative and other larger quality-related initiatives. Using this technology, you can go through huge volume of documents and extract information that specifically points to meaningful use data elements. This would include problem list, vital signs, allergies, social

history, procedures, medications and quality measure

information.



Real-time Patient Data – Hospitals can make use of this technology to provide quality analysts and physicians with valuable information about patients at the same time as they receive treatment. Once a record is completed, it is parsed and indexed for query searches. This capability will help hospitals to better diagnose the patient and provide quality treatment.

For example, hospitals use NLP to uncover the symptoms of sepsis immediately rather than retrospectively, which allows physicians to provide direct care for sepsis patients and thereby indirectly reduce readmission rates.

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

Carry Out Sophisticated Data Queries – NLP can scan large volume documents quickly to find terms related to quality measures and patient safety, which is quite time-consuming when done manually. The technology searches for explicit key terms, related terms, implicit conditions based on lab results or other indicators.

Overall, NLP significantly improves EHR documentation. Analyzing documentation and searches for certain conditions in real time will help to determine whether clinical documentation improvement specialists should query physicians while the patient is still in the hospital. Conducting concurrent queries can effectively reduce the number of post discharge queries as well as record holds. Hospitals can use this technology to identify records (for example, those involving one-day stays) that may be the target of RAC audit or other third-party audits.

Changing Role of Medical Transcriptionists With

this

new

technology

physicians

can

continue

in

place,

with

their

existing dictation styles. However, it is going

to

change

required

skill

transcriptionists

the

workflow

sets

of

(MTs).

and

medical

Like

speech

recognition, NLP also requires human intervention to review data and ensure that all documentation is tagged and parsed into the correct EHR fields. MTs will

have

the

reviewers/validators transcribers.

They

role

of

rather will

function

data than as

knowledge-based workers, ensuring the correctness of the results.

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1-800-670-2809

www.medicaltranscriptionservicecompany.com They will validate the following:



That discrete data elements and the document structure have been correctly captured before they are uploaded to the EHR or exchanged through an HIE (health information exchange). It is ensured that all concepts such as medications, allergies and other details are correctly encoded so that the EHR remains error free.



That clinical concept is encoded correctly before the document is submitted to a CDI (clinical documentation improvement) specialist or coder.



That the results of population health studies are correctly captured before they are presented to a case manager or researcher.

Projects are ongoing to create interoperable standards for the exchange and use of healthcare information that will allow providers to have structured clinical data while also retaining narrative information that is vital for human understanding. It may be possible in the near future to enjoy the advantages offered by electronically structured and encoded data and also retain the narrative created by traditional dictation and medical transcription. Physicians can make full use of medical transcriptionists’ knowledge and skill and thereby benefit from reduced effort, increased job satisfaction and improved documentation quality while also realizing maximum return on expensive investments in technology.

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1-800-670-2809