An expert system for clinical documentation improvement (CDI) is a specialized type of software that provides answers to problems, eliminating the need to consult a human expert.
When applied to a CDI program, the expert system collects and organizes clinical information, examining its own knowledge base and applying its rules, and thereby making its documentation expertise widely available throughout a healthcare organization.
The expert system approach has already been shown to be capable of providing a number of valuable enhancements to CDI, where its rules are applied to the clinical data that has been collected. For instance an expert system could:
● Examine the list of a patient’s medications and laboratory results and suggest additional diagnoses to be considered. This can be as simple as a reminder to add the diagnosis of “hypokalemia” when the serum potassium is low, or to consider congestive heart failure if the patient is taking Furosemide.
● Ask about possible infections when the patient is receiving an antibiotic but there is not bacterial infection diagnosis listed.
● Identify simple relationships among diagnoses, and make a comprehensive list of suggestions when there is “altered mental status” present.
● Put together more abstract diagnoses such as gastrointestinal bleeding and a low hemoglobin and hematocrit and suggest the user consider anemia, and additional suggestions looking to see if the anemia is caused by the GI bleed.
While an expert system cannot be expected to be better than the human expert, the system provides the ability to automate, process large amount of information, and to clone the expertise of the human expert. This becomes extremely helpful in improving efficiencies and in training new staff in the subtleties of CDI.
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