Healthcare organizations face an ever-growing burden of quality reporting requirements, from CMS quality programs and Joint Commission core measures to registry submissions for NCDR and Get With the Guidelines. AccuCode AI's clinical quality and compliance solution automates the identification, capture, and reporting of quality measures directly from your clinical documentation, turning what has traditionally been a resource-intensive process into a streamlined, reliable system that delivers exceptional accuracy.
Our platform handles the abstraction and reporting process automatically across all major registries and quality programs, with particular expertise in the most demanding and clinically complex reporting requirements. The system ensures compliance without the massive human resource investment traditional abstraction requires, allowing your organization to meet every submission deadline while maintaining the highest standards of data quality and accuracy.
The fundamental limitation of manual abstraction is the sheer volume of clinical documentation that must be reviewed. Consider that the average sepsis patient generates 174 pages of single-spaced, size 10 font documentation throughout their encounter. It is simply impractical for a human abstractor to read through all of it and perform an accurate abstraction in a reasonable timeframe. Manual abstractors typically focus on easily accessible summary information that is correct most of the time, but this approach inevitably misses critical data points buried deep in progress notes, nursing flowsheets, medication administration records, and ancillary documentation.
One of the most challenging aspects of manual abstraction involves positive and negative qualifiers. A single word can completely change an entire abstraction. Did the physician document "no evidence of" versus "suspicious for" versus "consistent with"? These qualifier words often come from extensive tables of approved terminology, and finding the exact word or phrase the physician used while buried somewhere in 174 pages of documentation is nearly impossible to do accurately day in and day out. Human abstractors simply cannot maintain the vigilance required to catch every qualifier variation across every patient record.
AccuCode AI ingests the entire medical record for each patient, not just summaries or subsets. Our platform analyzes every page, every note, every data point simultaneously and nearly instantly. This comprehensive approach allows us to identify supporting documentation that human abstractors would never find, catch critical qualifier words regardless of where they appear, capture nuances that summary reviews miss, and achieve over 100% accuracy relative to human abstractors. When a registry requires specific timing of interventions, exact medication dosages, detailed procedural information, or precise clinical terminology with the correct qualifiers, we find it regardless of where it appears in the medical record.
Our system operates on a batch processing model designed specifically for registry submission workflows. Organizations can identify their patient population for a given reporting period themselves, or our platform can automatically identify eligible patients based on registry-specific criteria. Once the population is defined, our platform processes those encounters against the specific requirements of your target registries. The system conforms to HL7 FHIR standards, ensuring seamless data exchange and interoperability with your existing health IT infrastructure.
Updates to registry specifications and data element definitions happen automatically as organizations release new requirements. Your abstraction remains current with the latest guidelines without manual intervention or workflow disruption. The platform generates submission-ready data files formatted precisely to each registry's specifications, eliminating the manual data entry and formatting work that traditionally consumes significant abstraction time.
Like our medical coding solution, clinical quality and compliance operates as a complete workflow replacement with human oversight limited to auditing purposes. Our platform performs the abstraction automatically, and your quality team reviews the results through an intuitive auditing interface. Each abstracted data element includes comprehensive justification and direct excerpts from the medical record showing exactly where the information was found and why specific values were assigned.
This transformation enables 90% or greater redeployment of abstraction staff. Nurses who have spent years performing manual chart abstraction can return to clinical roles where they directly impact patient care. The small team that remains in quality roles elevates from data entry specialists to quality assurance professionals, applying their clinical expertise to validate automated abstractions rather than spending countless hours reading through medical records and manually entering data into registry portals.
AccuCode AI has developed an approved Epic app available through the Epic App Orchard, making integration with Epic environments straightforward and intuitive. For organizations using other EMR platforms, our HL7 FHIR-compliant architecture ensures smooth integration regardless of your system. The platform pulls completed encounter documentation automatically, requiring zero changes to clinical workflows or provider documentation practices.
Your existing manual abstraction workflow is simply replaced. Clinicians document care exactly as they always have, encounters close through your normal processes, and our platform handles the rest. Your quality team accesses a centralized interface for audit and submission rather than logging into multiple registry portals and manually abstracting charts. The transition is seamless, allowing your organization to immediately realize the efficiency gains while maintaining full oversight and control over registry submissions.
