High fidelity clinical documentation improvement (CDI) smart scoring systems and methods

A clinical documentation improvement (CDI) system, comprising:

• a processor;
• a non-transitory computer readable medium;
• and
• stored instructions translatable by the processor to perform:
• receiving real-time medical data from a data source, the real-time medical data comprising clinical data for a patient and documentation for a visit of the patient;
• determining, based on the real-time medical data, a medical condition for the patient;
• determining, utilizing the real-time medical data, a difference between portions of the real-time medical data and stored data items the CDI system has for the visit of the patient;
• determining, based on the difference between the portions of the real-time medical data and the stored data items the CDI system has for the visit of the patient, a machine learning diagnosis model and a machine learning documentation model for analyzing the medical condition for the patient, the machine learning diagnosis model and a machine learning documentation model selected from a set of condition models for the medical condition;
• generating, an under-documentation score for the medical condition by applying the machine learning diagnosis model to the portions of the real-time medical data, the under-documentation score representing a probability that the medical condition is clinically valid but is not sufficiently documented;
• generating, an over-documentation score for the medical condition by applying the machine learning documentation model to the stored data items the CDI system has for the visit of the patient, the over-documentation score representing a probability that the medical condition is documented but is not supported by the clinical data for the patient;
• and
• generating, based at least in part on the under-documentation score and the over-documentation score, a CDI score for the visit of the patient.

A computer program product comprising a non-transitory computer-readable medium storing instructions translatable by a processor of a clinical documentation improvement (CDI) system to perform:

• receiving real-time medical data from a data source, the real-time medical data comprising clinical data for a patient and documentation for a visit of the patient;
• determining, based on the real-time medical data, a medical condition for the patient;
• determining, utilizing the real-time medical data, a difference between portions of the real-time medical data and stored data items the CDI system has for the visit of the patient;
• determining, based on the difference between the portions of the real-time medical data and the stored data items the CDI system has for the visit of the patient, a machine learning diagnosis model and a machine learning documentation model for analyzing the medical condition for the patient, the machine learning diagnosis model and a machine learning documentation model selected from a set of condition models for the medical condition;
• generating, an under-documentation score for the medical condition by applying the machine learning diagnosis model to the portions of the real-time medical data, the under-documentation score representing a probability that the medical condition is clinically valid but is not sufficiently documented;
• generating, an over-documentation score for the medical condition by applying the machine learning documentation model to the stored data items the CDI system has for the visit of the patient, the over-documentation score representing a probability that the medical condition is documented but is not supported by the clinical data for the patient;
• and
• generating, based at least in part on the under-documentation score and the over-documentation score, a CDI score for the visit of the patient.