![]() ![]() The tool did not need to be integrated in any other system. Memorial Hermann implemented the tool as a pilot with its hospitalist providers as they utilized the view of the EHR that incorporated the Chart Assist module. It can also identify documented diagnoses that lack appropriate clinical evidence. The AI portion of Chart Assist parses the health record to identify clinical evidence that supports missing diagnoses and diagnoses that lack specificity. These opportunities then are presented to the provider within their workflow, making it a natural part of their chart review process and supporting actions they can quickly take to update their documentation. "The content leverages Cerner's Ontology to label and classify structured data from the EHR and Cerner's Knowledge Library to group related medical concepts and diagnoses together, thus supporting semantic interoperability." A natural part of chart review "Using Cerner's natural language processing engine, along with clinical rules and algorithms, documentation is parsed and chart data is collected, looking for these opportunities," Okafor explained. "Using Cerner's natural language processing engine, along with clinical rules and algorithms, documentation is parsed and chart data is collected, looking for these opportunities." The entered diagnoses would be part of the providers' current note and future provider documentation as well. ![]() Chart Assist with Cerner.AI abstracts data from a patient's chart, concurrent with their hospital visit, and identifies opportunities to help ensure that the documentation accurately reflects the care provided.Ĭerner's proposal was to implement Chart Assist with Cerner.AI as the EHR prompts are as near real time as possible and within the providers' EHR MPage workflow. ![]() So the provider organization looked to its EHR vendor for a solution. Nnaemeka Okafor, vice president and chief analytics and informatics officer at Memorial Hermann. "The predominant method for capturing the missing or incomplete diagnoses in our organization is CDI queries that often are several days after the condition was managed the CDI query process is not within the physicians' workflow, and the newly entered diagnosis rarely gets propagated to future physician documentation," explained Dr. Clinical documentation improvement queries Over the last several years, the informatics division partnered with CDI specialists in the acute care venues to design and implement interruptive EHR alerts that prompt physicians to enter diagnoses when specific criteria are met. Houston-based Memorial Hermann Health System had a problem: Its providers often were not documenting all the diagnoses managed in the acute care setting.Ĭoders and clinical documentation-improvement specialists spend several hours each week educating physicians on the implications of missing or nonspecific diagnosis. ![]()
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