clinical documentation software

Clinical Documentation Improvement Solutions: Powered By NLP & AI

Improve EHR interoperability. A turnkey solution to automatically extract and route data from unstructured documents into your EHR system.

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streamline clinical documentation process

Streamlined clinical documentation for speed and precision.

Clarity Clinical Documentation (Clarity CD) software seamlessly routes patient information in structured and unstructured documents, including text, handwritten notes, fax images, and PDF files, to the appropriate patient record in your electronic health record (EHR) system — eliminating cumbersome, time-consuming, and error-prone manual data entry.

The intelligent solution uses state-of-the-art natural language processing (NLP) and artificial intelligence (AI) technologies to extract patient data like demographic information and clinical details with precision, automatically populating the data into a structured Continuity of Care Document (CCD). The advanced system routes data to your EHR via Consensus’ Direct Secure Messaging feature to ensure seamless, accurate, and secure integration.

Clarity CD is designed for today’s dynamic healthcare landscape, where precision and speed are paramount. You can consolidate patient data from multiple sources for a holistic view of each patient’s history to enhance efficiency, accuracy, and collaboration across healthcare teams.

We simplify the clinical documentation process, enabling healthcare professionals to focus on what matters: Delivering coordinated care and improving patient outcomes.

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Key Features of Consensus’s Clinical Documentation Software

Clarity Clinical Documentation (Clarity CD) is a product from Consensus designed to streamline the management of patient information in the healthcare industry. It emphasizes security, efficiency, and ease of use while meeting HIPAA compliance requirements. Clarity CD supports healthcare providers in delivering high-quality care with the following features:

  1. Extracts Structured Medical Content and Demographic Data: Enhances clinical workflows for improved care.
  2. Automated Data Application: Automatically applies data (such as patient IDs and demographic information) to the appropriate fields in digital forms.
  3. Data Flagging for Actions: Flags specific data points (like checkboxes and typed text) for immediate actions, such as clinician notifications.
  4. Confidence Scoring: Provides a confidence score for each extracted field to indicate accuracy.
  5. Continuous Learning: Enhances its intelligence over time with ongoing use.
  6. EHR Integration: Seamlessly integrates with Electronic Health Records (EHRs) to parse and populate patient records from digital faxes.

How Clarity CD works

The turnkey clinical documentation solution leverages intelligent NLP data extraction capabilities to transform unstructured documents like digital scans and faxes into structured, actionable data. Machine learning (ML) technologies automatically uncover valuable insights and send them to the right person at the right time to facilitate patient treatment across the care continuum.

How NLP & ML Power Up Clinical Documentation?

Our NLP technology helps clinicians and administrators interpret and consolidate unstructured documents, extract vital information, and gain actionable insights quickly and accurately. Automation supports prompt decisions and patient care to optimize treatment outcomes in healthcare settings where every minute counts. Clarity CD supports context-based understanding with advanced AI technology. The clinical documentation software reads an entire document and applies ML capabilities developed for medical understanding to interpret the information. It learns as it processes more information and becomes more intelligent over time. It also flags specific data points for actions, provides a confidence score for each field, and sends clinicians notifications for immediate attention.

Clinical Applications of NLP and ML

  • Shorten time to treatment
  • Optimize clinical workflows
  • Create CCDs from unstructured clinical documents
  • Support population health
  • Improve patient engagement

Administrative Applications of NLP and ML

  • Streamline pre-authorization
  • Improve referral management
  • Facilitate coding and claim processing
  • Automate document intake
  • Support public health initiatives
  • Facilitate quality reporting

4 Key Benefits of Clarity Clinical Documentation Improvement Software

Improve efficiency by more than 70% over manual data entry. Clarity CD accurately extracts patient data from a broad range of documents and images, including low-resolution faxes and digital scans of handwritten notes, to streamline processes:

Increase Operational Cost Efficiency

  • Streamline workflows and leverage intelligent automation to increase productivity and reduce costs.
  • Automate manual and repetitive tasks to lower administrative workload and overhead.
  • Avoid human errors (e.g., misfiled records) that can lead to costly consequences.
  • Integrate seamlessly with existing systems to enhance processes without disruptions.
  • Support accurate medical coding to improve revenue cycle management and cash flow.

Boost Provider Performance

  • Maintain consistent, reliable, and accurate patient records to coordinate care.
  • Prioritize clinical workflows, support data-driven decision-making, and deliver faster care.
  • Facilitate collaboration among providers with easy access to complete patient data.
  • Allow providers to dedicate more time to patient care instead of document processing.
  • Increase Healthcare Effectiveness Data and Information Set (HEDIS) scores.
  • Lower physician workload and prevent burnout by reducing time-consuming paperwork.

Improve Patient Care Quality

  • Build a holistic view of each patient to recommend the best treatment options.
  • Reduce errors to enhance patient satisfaction and improve clinical outcomes.
  • Ensure consistency across the care continuum with improved disease management and patient education.
  • Make accurate decisions when triaging patients and ordering tests, imaging, or procedures.
  • Improve the efficiency of clinical workflows for faster referrals and shorter time to treatment.

Enhance Data Security and Compliance

  • Meet regulatory requirements by reducing errors and maintaining an audit trail.
  • Ensure data security and protect patient privacy with HIPAA-compliant workflows.
  • Minimize the risks of human errors and oversight that could lead to data breaches.
  • Reduce security risks associated with on-premise infrastructure with a trusted cloud platform.

Step-by-Step Guide To Get Started With Consensus’s CDI Software

Clarity Clinical Documentation (Clarity CD) simplifies the management of medical documents. It handles everything from receiving various types of documents to ensuring the accuracy of extracted information and their integration into patient records. This process enhances overall patient care.

Step 1: Ingest

Clarity Clinical Documentation (Clarity CD) begins when an image is received. It could be in the form of an eFax, a digital scan, or a PDF file. In this step, the document is captured and digitized for further processing. The system ensures that the image quality is apt for accurate data extraction and analysis.

Step 2: Analyze

After the image gets ingested, the software analyzes the document to extract relevant clinical data. Here Optical Character Recognition (OCR) technology is used to convert handwritten or printed text into machine-readable text. Key information such as patient demographics, clinical notes, lab results is identified. The system then verifies the accuracy and completeness of the extracted data.

Step 3: Format

After analyzing the document, the software formats the valid data into a standardized Clinical Document Architecture (CDA) file using Continuity of Care Document (CCD) format. This ensures the data is organized consistently with the Consolidated Clinical Document Architecture (C-CDA) structure. This further makes integrating with electronic health record (EHR) systems easier. During this step, the software identifies invalid or incomplete data and notifies users, who can then review and correct any issues before proceeding.

Step 4: Transfer

Validated and formatted data is securely routed to the corresponding patient record in the EHR system. Secure transmission protocols are used to protect data during transfer, maintaining patient privacy and data integrity. The system maps the data to the correct patient record based on details such as patient name, date of birth, and medical record number.

Step 5: Populate

In the final step, the software populates the patient records in the EHR system by matching the extracted data with the correct fields. It ensures that all clinical information is accurately entered into the appropriate sections. This helps healthcare providers maintain comprehensive patient records, which enhances decision-making and improves patient care.

CASE STUDIES

Clarity CD adapts to different healthcare settings and helps organizations of all sizes increase productivity, improve patient care, and achieve operational excellence.

Clarity CD Industry Use Cases

Clarity CD facilitates inter-provider communication and enables evidence-based healthcare systems to automate decisions. It supports comprehensive documentation for legal records and patient registry functions to help public health agencies efficiently manage and research large patient populations.

The comprehensive clinical documents inform the creation of longitudinal patient records (LEPRs) to show healthcare information from all sources for an individual patient. Meanwhile, billing and coding staff can use these comprehensive records to facilitate claim submissions.

Here are the most common use cases for clinical documentation solutions in the industry:

Clarity CD streamlines patient admissions by automating and simplifying paperwork to increase operational efficiency and staff productivity while reducing costly errors. It enables effective care planning with a centralized platform to facilitate interdisciplinary collaboration. Providers can share patient notes and records to ensure everyone on the team has a holistic view of each patient’s history.

Complete clinical documentation allows primary care physicians to monitor their patients throughout the care continuum. Clarity CD facilitates the documentation of preventive care measures and immunizations to support proactive patient health management. It also ensures a seamless and error-free process if a patient needs to transfer records from a different practice.

Clarity CD leverages Consensus’ robust cloud-based security features to support secure and confidential information sharing among authorized healthcare professionals. By eliminating manual processes, patient information is less likely to be leaked or stolen, which is critical for maintaining patient confidentiality in a mental healthcare setting.

Providers in specialty clinics can gain a complete view of a patient’s health condition to ensure their care plan doesn’t conflict with other treatments or medications. Moreover, Clarity CD supports effective case management for chronic conditions by providing detailed and comprehensive documentation. Specialists can gain a holistic view of a patient’s medical history to ensure care quality and continuity.

Patients often work with different specialists and facilities for physical and occupational therapies. These professionals must collaborate with multiple healthcare providers to ensure care continuity as a patient recovers. Clarity CD facilitates information sharing by streamlining the process of collating treatment notes and patient records to align therapy plans with individual needs.

Clarity CD facilitates research documentation by ensuring all patient data is available to researchers for a comprehensive view of each individual without risking patient privacy and confidentiality. It also supports clinical trial documentation to ensure compliance and data integrity.

Time is of the essence in emergencies. Clarity CD enables rapid and accurate documentation of patient information in urgent care scenarios to ensure timely and appropriate treatment — especially when transferring a patient to a different facility or specialist for further care.

These facilities can use a clinical documentation solution to build comprehensive and easily accessible resident profiles. The records may consolidate medical history, medication records, care plans, and notes from facility staff (e.g., preferences, behaviors, dietary restrictions) to ensure personalized and consistent care.

Clarity CD makes it easy to keep a patient’s EHR up to date with information from different healthcare providers. It allows in-home healthcare professionals to access the latest patient history remotely to ensure continuity of care outside traditional healthcare settings.

With Clarity CD, health insurance companies can facilitate efficient claim processing with a standardized system to ensure accurate documentation of patient encounters and treatments. Meanwhile, billing and coding specialists can leverage comprehensive patient records to reduce errors, save time, and get faster reimbursement.

Incorporating a new component into your healthcare tech stack can be complex. Every implementation is different and must be orchestrated to meet your unique requirements, fit into the existing infrastructure, and complement current workflows.

Our team is available to provide integration consultation and ensure our solution meets your needs. Request a meeting to see how Consensus and Clarity CD can help you streamline processes, increase cost-efficiency, and enhance security and compliance.

Healthcare and adjacent industries have become more competitive than ever. Organizations must use the latest technologies to automate workflows, reduce costs, and improve productivity without losing sight of data security and compliance requirements.

Manual data entry causes errors and delays that negatively impact care continuity, treatment outcomes, and patient experience. It may also affect claim processing, hurting your cash flow and financial health.

Clarity CD features the latest NLP and ML technology, supported by Consensus’ advanced cloud platform and eFax Corporate’s secure digital faxing solution, to help healthcare organizations process patient data accurately and efficiently across the care continuum. Request a demo to see how we can help you modernize the data intake process:

Unlock the power of precise medical communication and streamlined clinical documentation

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FAQS

CDI software automatically extracts data from unstructured documents and routes it into an EHR system.

Yes, Consensus’s clinical documentation solutions can be seamlessly integrated with your existing systems, including Electronic Health Record (EHR) systems, to streamline your entire workflow.

Consensus’s Clarity Clinical Documentation (Clarity CD) software simplifies your clinical documentation process. It automatically sorts patient data from different sources into your electronic health record (EHR) system. With advanced technology, including a Direct Secure Messaging feature, it ensures the accuracy of the records and enhances collaboration among healthcare teams, prioritizing patient care and outcomes.

Some must-have features of a clinical documentation system include:

  • Integration with EHR systems
  • Automated data capture
  • Advanced analytics
  • Natural Language Processing (NLP) capabilities
  • Secure and compliant data storage
  • User-friendly interface

Yes, your patient data is secure with Consensus. Our solution complies with all relevant healthcare regulations, including HIPAA. It uses advanced security measures to protect patient’s privacy and information.

Medical documentation with EHR is important because it ensures accurate, and complete patient records. Due to the availability of these accurate details, treatment errors are avoided and patient care is improved. It also supports billing and regulatory compliance.

NLP (Natural Language Processing) technology aids with clinical documentation processes by automatically interpreting and processing clinical notes along with unstructured data. It extracts relevant information, suggests corrections, and enhances the overall accuracy of documentation.