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Putting clinical documentation in context for the EHR

Clinical Document Architecture

More than 80% of critical patient data exists in unstructured form. Clinical Language Understanding (CLU) translates unstructured input — speech — into structured and standardized data elements that can populate the EHR. Clinical Language Understanding (CLU) leverages advancements in Natural Language Processing (NLP) and Artificial Intelligence (AI) to create tailored solutions for healthcare informatics. CLU ‘understands’ both the clinical concepts and their context. For example, CLU can delineate the word “discharge” from the nose, a symptom, from hospital “discharge,” the end of a patient encounter.

Clinical Document Architecture (CDA) provides the framework to format CLU data and share it across organizations and systems. CDA is an ANSI-certified standard from Health Level Seven (HL7). It is an XML-based document markup standard that specifies the structure and semantics of a clinical document for the purpose of exchange. A CDA document can include text, images, sounds and other multimedia content and it possesses six characteristics:

  1. Persistence
  2. Stewardship
  3. Potential for authentication
  4. Context
  5. Wholeness
  6. Human readability

Typical CDA documents include discharge summaries, imaging reports, admission and physical documents and pathology reports, among others.

As a supporting member of The Health Story Project (formerly CDA4CDT), Nuance contributes to ongoing development and fostering of CDA standards to enhance the flow of clinical information between narrative dictations and the EHR.

How Nuance makes a difference

  • Increases the amount of meaningful data healthcare organizations can use for clinical decision making
  • Improves patient care by providing a richer and more complete image of the patient
  • Reduces operational costs
  • Helps organizations achieve meaningful use by unlocking clinical data from narratives
  • Maximizes the clinical value of transcribed and dictated notes

Better, safer patient care
Nuance solutions give healthcare organizations more meaningful data for clinical decision making, leading to improved patient care and reduced healthcare costs.

Meaningful use
By helping collect and report on various diagnostic, quality and safety measures, Nuance solutions help healthcare organizations advance their efforts to qualify for Meaningful Use reimbursements associated with certified EHR technology, as outlined in the HITECH Act.