Structured Data from Unstructured Documents
BayScribe extracts clinical information from unstructured clinical documentation (both written and spoken) and creates Structured Data that supports Meaningful Use and Collaborative Care. BayScribe uses NLP to create structured data from previously unstructured dictated and handwritten notes; data that can aid the entire care team in providing quality, timely patient care. The structured data is coded with ICD-9/10, CPT, SNOMED, RxNorm, CVX and other code sets to provide semantically interoperable clinical documents.
How does it work?
BayScribe receives the unstructured note and instantly process the document through NLP (Natural Language Processing) to extract the clinical concepts, including Problems, Medications, Allergies, Immunizations, Procedures, etc. Then the now structured document is processed against the industry-leading IMO terminologies product suite to acquire the appropriate codes (ICD 9/10, CPT, LOINC, RxNorm, CVX, etc). Finally, the now codified document is ‘packaged’ as a Level 3 CDA XML document to be exported into your EHR and/or HIE for patient care. Click here and see it work!
What does this mean?
It means that your patient documentation doesn’t have to be created in the EHR to be interoperable and actionable.
Quality, Clinical Documentation Improvement (CDI), Present on Admission (POA) & Core Measures reporting, as well as meeting Meaningful Use, are dependent on Semantically Interoperable Documents, and the creation of these documents can be facilitated by BayScribe’s ability to extract the data needed to facilitate care. Process H&P’s quickly and distribute key findings to inform the Care Team and expedite the care-giving process. Has a CHF patient been re-admitted? Better to find out while they are still in the hospital as opposed to thirty days after they have been discharged! Is a Nutrition consult needed? Does the Tumor Registrar need to be notified? Have the system proactively notify your Care Team instead of waiting and reacting.
Notice that the PROCEDURES (below) are extracted from all locations (source) within the dictated note. This is NOT structured dictation, but rather structured data from unstructured dictation. The same workflow is viable with handwritten notes through our Digital Ink solution.
Valuable data can be provided to numerous teams throughout the care giving process to improve efficiency and quality of care, as well as positively impact reimbursement!
Here is a sample of a real Report and the NLP findings. Click to enlarge and take a closer look.
