Integrated Solution Drives Enhanced Clinical Documentation Process Directly Within Cerner Millennium
Nuance Communications, Inc. and Cerner Corporation recently announced that Cerner will incorporate Nuance’s clinical documentation improvement (CDI) technology and professional services to help clinicians seamlessly create the most accurate and complete clinical documentation at the point of care. The integrity of clinical documentation is a critical component of a providers’ overall information management strategy and is directly tied to improved patient care, appropriate reimbursement, quality reporting and enhanced compliance.
As healthcare providers look to confront the drastic changes brought on by regulatory mandates such as ICD-10, value-based purchasing and various quality reporting initiatives, they’re increasingly realizing the vital role clinical documentation plays in their information management strategy and across various patient and business touch points in their organizations.
At a recent Office of the National Coordinator HIT Policy Committee meeting, the pressing need to address current clinical documentation programs was further reinforced by the American Health Information Management Association (AHIMA). Citing growing adoption of electronic health records (EHR) and initial progress toward an era of information sharing across healthcare systems, AHIMA reinforced the need to establish immediate clinical documentation best practices.
“To ensure the integrity of the information going into the electronic health record, clinicians need both technology and guidance that doesn’t interrupt their workflow,” said Max Reinig, senior vice president of Physician Solutions for Cerner. “By integrating Nuance’s clinical documentation improvement content and automated decision-support technology with our EHR and Cerner Care Management solution, clinicians will be presented with a seamless workflow that ensures the quality of physician documentation.”
The integration of Nuance’s CDI solution within Cerner’s EHR and Revenue Cycle solutions will help healthcare providers improve the quality and accuracy of their clinical documentation in real-time at the point of care, supporting both clinicians’ and CDI specialists’ workflows. The technology will be used concurrently to give feedback to physicians on the information needed to complete the record and will provide CDI specialists with the tools necessary to improve their analysis of the physician’s documentation.
In line with this partnership, Cerner will deliver the following solutions powered by Nuance technology and services:
Cerner Care Management – Powered by Nuance’s proven J.A. Thomas CDI content and compliant documentation management program, this integrated solution will provide specialized content necessary for modeling a more specific working Diagnosis-Related Group resulting in a more efficient workflow and increased productivity for the clinical documentation specialist. This solution automates and supports the workflow of the CDI specialist within Cerner PowerChart, the clinician’s view of Cerner’s EHR.
The Cerner Document Quality Review (DQR) Module – Powered by Nuance’s Computer-Assisted Physician Documentation (CAPD) solution, the DQR module facilitates complete, accurate and concurrent documentation by automating the CDI process. Physicians will interact with CDI clarifications and findings real-time at the point they are writing their notes. This will greatly improve both physician productivity as well as the integrity of their documentation and the discrete information captured within PowerChart, Cerner’s EHR.
“Expanding our partnership will enable providers to tackle the complexity of clinical documentation with the simplicity of a best in class solution that integrates our J.A. Thomas CDI expertise and voice-enabled clinical language understanding technology with Cerner’s market-leading electronic health record,” said Janet Dillione, executive vice president and general manager, Nuance Healthcare. “What’s truly unique about Nuance’s solution is that we embed the CDI process directly in the physician workflow so information gaps are addressed immediately while the physicians are documenting instead of days or even weeks after the patient visit.”
To learn more about how this Nuance-Cerner partnership will help simplify the complexities of clinical documentation and streamline information management for healthcare providers, please visit booth #4025 and #4941 at HIMSS 2013.
Cerner is contributing to the systemic change of health and care delivery. For more than 30 years Cerner has been executing its vision to make health care safer and more efficient. We started with the foundation of digitizing paper processes and now offer the most comprehensive array of information software, professional services, medical device integration, remote hosting and employer health and wellness services. Cerner systems are used by everyone from individual consumers, to single-doctor practices, hospitals, employers and entire countries. Taking what we’ve learned over more than three decades, Cerner is building on the knowledge that is in the system to support evidence-based clinical decisions, prevent medical errors and empower patients in their care.
Cerner solutions are licensed by approximately 10,000 facilities around the world, including more than 2,700 hospitals; 4,150 physician practices; 45,000 physicians; 550 ambulatory facilities, such as laboratories, ambulatory centers, behavioral health centers, cardiac facilities, radiology clinics and surgery centers; 800 home health facilities; 45 employer sites and 1,750 retail pharmacies.
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About Nuance Healthcare
Nuance Healthcare, a division of Nuance Communications, is the market leader in creating clinical understanding solutions that drive smart, efficient decisions across healthcare. As the largest clinical documentation provider in the U.S., Nuance provides solutions and services that improve the entire clinical documentation process — from the capture of the complete patient record to clinical documentation improvement, coding, compliance and appropriate reimbursement. More than 450,000 physicians and10,000 healthcare facilities worldwide leverage Nuance’s award-winning, voice-enabled clinical documentation and analytics solutions to support the physician in any clinical workflow and on any device. For more information, visit www.nuance.com/for-healthcare/index.htm.
About Nuance Communications, Inc
Nuance Communications, Inc. is a leading provider of voice and language solutions for businesses and consumers around the world. Its technologies, applications and services make the user experience more compelling by transforming the way people interact with devices and systems. Every day, millions of users and thousands of businesses experience Nuance’s proven applications. For more information, visit http://www.nuance.com/