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Achieving clinical documentation improvement with automation and AI

Improving administrative efficiencies with automation and AI, Part 2

Welcome to Part 2 in our series on how home and hospice care providers can use automation and AI to improve operational efficiencies. In case you missed it, you can check out Part 1 here.

As we’ve seen in the first part of this series, the use of AI and automation can help you create a better, more structured system for keeping intelligent records. That can be a powerful tool in boosting the efficiency and output of your administrative team. More importantly, though, this new tech can be a game-changer in clinical documentation improvement.

The idea is to bring greater structure to clinical data. Systems you already use, like OASIS or HIS, are already structured—but they’re also fragmented, leaving far too much for busy, sometimes distracted workers to fill in the gaps. Automation and AI offer a larger framework to tie them together while minimizing error and repetition.

Think of the documentation that’s currently in the hands of your nurses and clinicians. It can be a challenge for them to navigate systems like OASIS and HIS while still focusing on their immediate duties. Automating parts of this system will help make their jobs easier and provide you with a more reliable source of information.

Upon that foundation of clinical documentation, you can build processes that are specific to your operational needs. For instance, if pain assessments are part of your standard operating procedure, an automated system can help you control that requirement and build it into the logic of your entire organization.

The idea is to set up a structure that allows workers to move readily through assessments, taking them automatically to the questions they need to answer and letting them skip the ones they don’t. They also should have the ability to loop through all the data from these networks for different patients to extract medication data, diagnosis information, allergies, and other crucial information as needed, instead of having to manually search each time.

Bringing clinical documentation improvement to your existing processes

Even with an effective system like this in place, inefficiencies can still arise. No matter how structured data in healthcare becomes, it will never fully replace the human intelligence needed to give a true description of the patient’s condition.

When recording data, clinicians are often left with no choice but to fill their observations into a big narrative block. And typing out an 8,000-character summary takes time—leaving clinicians to either sit in front of the patient and type for 20 minutes or have to take their work home.

The process is inefficient, and the further away from the point of care the narrative is, the shorter and less accurate they become. And that all tends to “dumbs down” the pivotal human intelligence.

Instead of requiring workers to abandon their system of narrative information flows, the use of AI can better capture the important details of that narration. The clear opportunity is for the application of tools like speech-to-text—a feature that MatrixCare has worked to pioneer through our partnership with nVoq.

At its core, speech-to-text is a complex intelligence that loops through streamed audio and turns it into a narrative text that can be added into a record. However, as powerful as they have become, these tools have their own weaknesses. This is especially true in consumer marketplaces where it’s easy to send a nonsensical message or command when using common app-based speech recognition tools. Using these tools in a healthcare setting needs refinement. You can’t use just any tool; it must be enhanced with the right AI and medical focus.

Speech-to-text AI designed for healthcare can circumvent this problem by using powerful engines that enable human intelligence to support the structured assessment data capture for clinicians. Your OASIS questions, or other applicable systems/assessments, are combined with sophisticated voice recognition technology to help your employees operate more efficiently. It helps systems more accurately capture and categorize information, enabling clinical documentation improvement where it matters most.

Achieving continuous improvement with automation and AI

Improving administrative efficiencies through AI and automation comes down to management by exception. It’s about isolating the anomalies and dealing with them on a case-by-case basis. Everything else can and should be automated, when and where it’s possible.

Beyond these important administrative efficiencies, AI also drives continuous improvement. It’s about taking your existing standards and processes and making them better—not just more reliable, but faster and more efficient, every quarter, every year. In the process, you’re empowering your back-office staff to do more with their time, giving your entire organization more room to grow.

Want to learn more about how MatrixCare can help you leverage automation and AI? Let’s connect!


Chris Pugliese
Chris Pugliese

Chris Pugliese is a Senior Product Manager of Integration and Interoperability for MatrixCare. Chris has spent the last decade working with post-acute technology and EMRs, and the last 5 years focused on interoperability. His strength is enabling technology, as well as educating on the growing importance of interoperability and its benefits to the post-acute care settings. In a short time, Chris has become a leader, spearheading integration and interoperability initiatives within and outside of MatrixCare. Recent industry committee roles and responsibilities include: Leadership Team Member for the Post Acute Interoperability Work Group (PACIO), Technical Lead for the Functional Status Subgroup for the PACIO initiative – developing FHIR Profiles for Functional Status, CommonWell Health Alliance Use Case Committee member, CommonWell Health Alliance Specification Workgroup member


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