a hands free solution to medical documentation and billing
Featured on the AWS Partner Network Blog: How AWS Machine Learning Services Increase Medical Coding Accuracy and Efficiency
SmartNoteMD is a completely different way of documenting medical notes and billing codes. While good intentioned, the HiTech Act of 2009 pushed the healthcare industry into a space that wasn't quite ready and added hours to a physician's day. The process should be seamless, and now, with the help of AWS, SmartNoteMD is poised to replace an otherwise tedious and impersonal requirement.
how it works
SmartNoteMD listens in the background while you evaluate and treat your patient. Like the popular "Amazon Alexa," certain keywords and phrases allow SmartNoteMD to automatically populate a medical note and select the relevant procedure and diagnosis codes.
SmartNoteMD uses AI and Machine Learning to create the relevant content in your medical note. If you don't like what you see, the medical note and selected billing codes can be edited for accuracy. Once it's perfect, sign off for authenticity and/or add an addendum later.
Select one note, an entire day or a patient's chart, and export via email, text or air drop in one of the following formats: pdf, xml, json, plist, html, reduced json or reduced xml.
In the device settings, you can set the "Fuzzy Search" threshold. This determines how probable a given sound is to matching a particular word. For example, if SmartNoteMD hears "a seat and then" it will weigh the probability of it to mean "acetaminophen" based on the threshold setting.
If you want to be completely hands free, you can set SmartNoteMD to begin listening when it hears you talk and stop listening after several seconds of silence.
To improve the accuracy of your medical coding selection, choose your specialty. Then while SmartNoteMD listens to you, it will only select the billing codes applicable to the type of treatment you provide.
To improve the accuracy even more, you can create a Custom Set of diagnosis codes within the selected specialty or from the entire library.
MEET THE TEAM
Creative Practice Solutions is a business consulting company geared towards Medical Professionals. With over 30 years experience in healthcare administration, they have improved the functioning, efficiency and collections of both private practice and outpatient hospital departments throughout New York City. CPS has contributed blogs, editorials and professional opinion in the industry resources; PhysiciansPractice.com, BC Advantage Magazine, MedPageToday.com and the AAPC's Business Healthcare Monthly. They also developed a CME/CEU activity on the Business of Healthcare through a joint sponsorship with the New York State Medical Society.
Amazon Web Services is a subsidiary of Amazon providing on-demand cloud computing platforms and APIs to individuals, companies, and governments, on a metered pay-as-you-go basis.
Is SmartNoteMD secure and HIPAA compliant? Yes! The applications are architected for HIPAA compliance with built-in security controls and HIPAA-eligible services such as Amazon Comprehend Medical. They also incorporate security and data privacy best practices, including encryption at rest and in transit, audit trails, and multi-factor authentication.
Do I have to let the patient know that SmartNoteMD is listening? It depends on your state regulations. Many states only require one party to be aware of the recording. We have supplied a "Listening Consent Form" in SmartNoteMD that can be printed and signed. The patient can also verbally agree during the appointment.
Where do the recordings go? The data that SmartNoteMD hears is stored in the Amazon S3 storage solution. Amazon S3 allows us to block public access to all of our data. S3 also maintains compliance programs, such as PCI-DSS, HIPAA/HITECH, FedRAMP, EU Data Protection Directive, and FISMA, to help us protect your information.
S3 also uses Server Side Encryption powered by AWS KMS w/ AES256 algorithm, meaning that the stored data is not accessible by AWS.
It enforces TLS connections for all operations, meaning that no data is passed unencrypted through networks.
The data is replicated across different geographies in one AWS region located distantly. Hence, in case of environmental disaster, the chances of lost data are negligible.
All the data is only accessible by its owner: Amazon Cognito enforces separation of records per doctor.
After uploading into the cloud, data no longer traverses public Internet – all communications are conducted through AWS barebone network w/ the help of Amazon VPC Endpoints (a.k.a. PrivateLink)
Does it only work on Apple devices?
Currently SmartNoteMD is only available on the iPhone, iPad, Apple TV and Mac. Future versions will be web based and android compatible.
As mentioned at the top of the site, SmartNoteMD uses a completely different method for creating documentation. Certain key words and phrases trigger specific fields and billing codes for your medical note. A printable cheat sheet is available under Show Agreements in the Settings page of the actual application. For best practices, post it in the treatment room to keep you on track.