Accurate documentation is the foundation of quality healthcare. Yet achieving it remains a formidable challenge, one that plagues virtually every health system across the U.S.
Inconsistent or incomplete clinical notes can hinder patient care, disrupt workflows, and cause costly errors downstream. But how can provider organizations avoid these issues when their physicians are forced to navigate complex systems like ICD-10-CM and SNOMED CT® at the point of care, documenting with the utmost specificity?
One promising tool is Ambient clinical intelligence (ACI), also known as ambient clinical documentation. Through clinical AI (artificial intelligence) and natural language processing (NLP), ambient AI technology records and analyzes healthcare encounters in real time. As a result, the application improves documentation accuracy, boosts reimbursement, and optimizes physician workflows.
The secret ingredient? Rich clinical terminology. Without it, ACI tools can only capture and interpret patient encounters at surface level—they can’t accurately convert free text into structured, coded, highly specific clinical data. In other words, comprehensive clinical terminology is essential for ensuring the accuracy and actionability of ACI-driven documentation. As the trusted clinical terminology partner to every major EHR vendor in the country, this is our bread and butter.
With more accurate documentation, providers can make smarter healthcare decisions and submit cleaner claims for higher reimbursement. But the benefits of ACI extend beyond decision-making and billing. By alleviating the administrative burden that plagues physicians, ambient technology empowers clinicians to spend more time engaging with their patients—sans screens. In turn, this can strengthen relationships, care outcomes, and physician satisfaction.
Learn more about ambient AI technology and its potential to enhance documentation accuracy with clinical terminology in our latest insight brief.
INSIGHT BRIEF
Harnessing the potential of ambient AI: Optimizing workflows, reducing burnout, and improving patient interactions
Short on time? Keep reading for a preview of the brief’s insights.
Importance of comprehensive terminology
Incorporating rich clinical terminology into ambient AI applications is essential for accurately documenting medical diagnoses and mapping them to standardized codes. Ambient AI vendors can enhance their technology with complementary solutions grounded in comprehensive, always up-to-date terminologies to achieve the most robust results and facilitate downstream processes. For example, to populate a patient chart based on a conversation, a vendor can leverage an external tool to ingest the transcribed note and receive a list of problems, procedures, medications, and labs that can be organized for the user to review.
Core benefits of integrating ACI with comprehensive terminology include:
Enhanced data capture and interpretation: Rich clinical terminology enables ACI to identify and encode a diverse set of medical concepts, ensuring that critical details aren’t missed during patient visits and preserving clinical intent. This leads to more complete and nuanced data that can be seamlessly integrated across various systems, supporting better workflows and decision-making. Integrating solutions backed by comprehensive terminology also helps organizations gather the complete and specific documentation they need to optimize reimbursement.
Improved accuracy: By automatically mapping diagnoses to standardized codes via detailed terminology, ambient AI reduces the risk of misinterpretation or errors in the EHR. This level of precision improves the reliability of patient records, leading to more accurate billing, improved ROI, and better patient outcomes.
Eager to learn more about ambient AI and documentation accuracy?
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