Natural Language Processing extracts the Data you need.
BayScribe utilizes the MedLEE Portal for Natural Language Processing (NLP). MedLEE is the result of 20 years of research and development by Columbia University school of medicine and is recognized as the gold-standard in NLP technology.
Present on Admission (POA), Core Measures (CMS) and Meaningful Use are facilitated by BayScribe's ability to extract the data needed to facilitate care. Process H&P's quickly and distribute key findings to inform the Care Team and expedite the care-giving process. Is a Nutrition consult needed? Does the Tumor Registrar need to be notified? Have the system proactively notify your Care Team instead of waiting and reacting.
Glean data and publish encoded results to the Revenue Cycle team members for accurate Computer-Assisted Coding of billable events.
Here is a sample of a real Report and the NLP findings.
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ADMISSION DIAGNOSIS:
Tachycardia.
DISCHARGE DIAGNOSIS:
Menopausal symptoms.
CONDITION ON DISCHARGE:
Improved.
PROGNOSIS:
Excellent. BRIEF CLINICAL SUMMARY: Ms. Washington is a very pleasant 56-year-old African American female who was in her usual state of good health. While in church Sunday, she began with a warm flushed feeling all over her body, which progressed to being extremely hot. She noticed that she broke out into a profuse sweat, and then became somewhat lightheaded and dizzy as she felt her heart rate begin to increase. She became extremely concerned about this, and her friend who attended church with her called 911. Apparently, when 911 arrived, the apparently tried a Valsalva maneuver which did not affect the heart rate. She had previously discontinued her hypertensive medications two weeks prior to this episode. The documentation by the paramedics indicates that their monitor showed a sinus tachycardia rate of about 110 beats per minute, and the patient was subsequently transported to the emergency room at Typical Hospital. From there she was admitted to rule out tachycardia and rule out MI. Since her admission to Typical Hospital, she underwent cardiac enzymes which were entirely within normal limits. Her telemetry monitor showed only normal sinus rhythm, heart rates between 80 and 98 beats per minute. There were no extra systoles noted throughout her entire hospitalization. She also had a 2D echocardiogram, which showed an EF of 60%, normal wall motion, normal valves, and absence of pericardial effusion. She also had an exercise stress test where she exercised 6 minutes 45 seconds, completing 45 seconds of stage 3 Bruce protocol, achieving her maximal predicted heart rate of 166 beats per minute and achieving 8 Mets. There were no EKG changes, no arrhythmias noted, and the patient had no symptoms whatsoever. Her blood pressure had a mild hypertensive response to exercise, and increased from 140/98 to 200/96. Her primary care physician, Dr. Gerald Ford's office, was contacted as was her gynecological physician Dr. Richard Nixon. In collaboration with Dr. Nixon, it was determined that her admitting episode was clearly not cardiac in etiology, but appeared to be most consistent with a "hot flash episode" secondary to menopause. Subsequently, hormone replacement therapy was recommended.
PAST MEDICAL HISTORY:
Past medical history is significant for an increase in heart rate eight years ago, but no formal evaluation. There is a history of medication noncompliance when she stopped her antihypertensive medications two weeks ago. She has a history of anemia, is status post left nephrectomy secondary to renal calculi, and is status post hysterectomy with left oophorectomy and salpingectomy.
ALLERGIES:
Sulfa.
CURRENT MEDICATIONS:
Aspirin, 325 mg p.o. q.d.
FAMILY HISTORY:
Her sister has hypertension and diabetes. Her father died at age 88 from hepatic cancer and had a history of hypertension. Her mother died with an acute MI at age 56.
SOCIAL HISTORY:
She lives alone, is a nonsmoker, rarely uses alcohol (only socially), and denies a history of recreational substance use.
PHYSICAL EXAMINATION:
Her blood pressure was 167/100, heart rate 76, respirations 20, weight 138 pounds. Skin was warm and dry. Lungs were clear to percussion and auscultation. Neck was supple. Carotids were without bruits. No thyromegaly. Heart had normal S1, normal S2, soft S4, no S3. Point of maximal impulse was nondisplaced. No JVD, no HJR. Extremities were without clubbing, cyanosis or edema.
LABORATORY DATA:
Two-dimensional echocardiography and exercise stress test as previously listed. Sodium 140, potassium 4.0, chloride 106, CO2 27, BUN 10, creatinine 1.0, glucose 78. Calcium was 9.1, magnesium 2.0, troponin-I was less than 0.01, CK-MB was 2.76, and CK was 89. Her TSH was 1.25. Hematocrit was 35.9. Electrocardiogram showed normal sinus rhythm, rate 98 beats per minute, and was within normal limits. IMPRESSION 1. Menopausal episode. 2. Tachycardia secondary to menopausal episode. 3. Medication noncompliance. 4. Labile hypertension, uncontrolled.
PLAN:
We would like to make the following recommendations on this patient: 1. Norvasc, 5 mg p.o. q.day should be discontinued. Zestril, 5 mg p.o. q.d., should be used in its place and titrated to maintain a normotensive state. Although the patient has only one kidney, the ACE-1s have been shown to be extremely nephroprotective. 2. A two-dimensional echocardiogram has been performed, results of which are listed above. 3. A non-nuclear exercise treadmill stress test has been performed, with results as listed above. 4. The patient should have a fasting lipid profile which has been drawn; results are pending. 5. An FSH level and Estradiol level should be drawn on this patient, which is at the request of Dr. Epstein. 6. The patient should maintain a two-gram sodium, low-fat, low-cholesterol diet. 7. This patient should avoid the use of grapefruit juice and grapefruit products at all times. 8. Hormone replacement therapy should be instituted as soon as possible in this patient, which is the request of Dr. Epstein. DISCHARGE MEDICATIONS 1. Aspirin, 81 mg p.o. q.day. 2. Zestril, 10 mg p.o. q.day.
DISCHARGE DIET:
Two grams sodium, low-salt, low-fat, low cholesterol.
DISCHARGE ACTIVITY:
Ad lib, where the patient should incorporate 20 to 30 minutes of exercise three times a week into her routine.
DISCHARGE INSTRUCTIONS:
Follow up will be with Dr. Richard Nixon (410)777-9400 as soon as possible for evaluation for and to start hormone replacement therapy and calcium supplementation. Follow up should also be with Dr. Gerald Ford (410) 777-4000 within one to two weeks of discharge. In the event that the patient should warrant closer cardiovascular followup, we are most happy to see the patient on an outpatient or inpatient basis Thank you for referring this most pleasant patient to us. We look forward to following the patient with you.