Distribution

Clinical Document Architecture (CDA)

Clinical Document Architecture (CDA) is the interoperable standard for integrating structured data into the EMR/EHR.

According to Nuance, greater than 80% of critical patient data exists in unstructured form. BayScribe’s Natural Language Processing (NLP) system converts unstructured input — handwriting & speech — into structured  data elements that can populate the EHR. Furthermore, our integration with IMO allows for the codification of those data elements, including ICD-9/10, CPT, SNOMED, RxNorm, CVX and many others.

This advanced Clinical Documentation System provides many benefits to support medical informatics and the CDA is the proverbial ‘last mile’, in that without the CDA there is no mechanism for the EHR/EMR to digest the data from the free text. In other words, an HL7 v 2 message isn’t enough. If your transcribed reports flow into Epic, as an example, Epic doesn’t “know” if there is clinical or diagnostic data in that HL7 message. It is merely ‘text’.

CDA provides the framework to format the NLP/IMO data and share it across organizations and systems. CDA is an ANSI-certified standard from Health Level Seven (HL7). It is an XML-based document markup standard that specifies the structure and semantics of a clinical document for the purpose of exchange, and it is vetted against NIST (National Institute for Standards & Technology). Typical CDA documents include discharge summaries, imaging reports, admission/ history & physical documents and pathology reports, among others.  BayScribe supports two types of CDA output — the Continuity of Care Document (CCD) and the more granular version used by government, the C32.

Read more…

Auto-Print whenever, wherever

Upon submitting the final report, whether by an Editor, Transcriptionist or Author, the document is merged into a series of templates.  The RTF template allows the document to be distributed in ways consistent with Microsoft Word.

Typically this results in printing the report.  BayScribe allows different workflow rules to be created to simplify this process so that reports can automatically print to different printers based upon the characteristics of the document, such as:

• the referring individual or cc’s,
• the Author of the report,
• the Report type,
• the Department,
• the medical record number,
• the client, case or matter number, etc.

Furthermore, the RTF can be easily saved into document management systems as needed. BayScribe truly maximizes productivity for all individuals involved in the Report creation process.

Auto-Fax

Upon submitting the final report, whether by an Editor, Transcriptionist or Author, the document is merged into a series of templates.  The Facsimile template allows the document to be distributed via our Fax Partner, InterFax or through RightFax Server. The transmission of the data is secure.

BayScribe allows different workflow rules to be created to simplify this process so that reports can automatically fax to different locations based upon the characteristics of the document, such as:

• the Author of the report,
• the referring individual or cc’s,
• the Department,
• the medical record number,
• the Report type,
• the client, case or matter number, etc.