NLP to Enhance Your Hospital Documentation
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The document discusses the benefits of using Natural Language Processing (NLP) to improve hospital documentation by extracting structured data from unstructured narratives in electronic health records (EHR). NLP aids in efficient data entry, real-time patient information retrieval, and sophisticated data querying, ultimately enhancing the quality of care. Additionally, the role of medical transcriptionists will evolve from transcription to data validation and review due to the integration of this technology.
NLP to Enhance Your Hospital Documentation
- 1. www.medicaltranscriptionservicecompany.com CALL US: 1-800-670-2809 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.
- 2. www.medicaltranscriptionservicecompany.com CALL US: 1-800-670-2809 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.
- 3. www.medicaltranscriptionservicecompany.com CALL US: 1-800-670-2809 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 in place, physicians can continue with their existing dictation styles. However, it is going to change the workflow and required skill sets of medical transcriptionists (MTs). 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 role of data reviewers/validators rather than transcribers. They will function as knowledge-based workers, ensuring the correctness of the results.
- 4. www.medicaltranscriptionservicecompany.com CALL US: 1-800-670-2809 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.