Health Information Management

Ask the expert: Can you explain the difference between structured data input and natural language processing in terms of computer-assisted coding software options?

HIM-HIPAA Insider, June 5, 2007

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A: There are two main different types of CAC software: structured data input (SDA) and natural language processing (NLP), and vendors tend to focus on one versus the other.

With SDA, the end-user is the physician. The software presents the physician with a limited set of medical choices used to generate documentation, and then the computer assigns a code based on that documentation.

For example, when a physician performs a colonoscopy, the SDA software might prompt him or her for the following information before assigning a code:

  • Procedure indication
  • Medicine used during the procedure
  • What the physician found and performed during the procedure
  • What he or she recommends

With NLP, the software requires that the facility have some type of electronic document even though it does not require a complete electronic health record. It then looks for certain words and the context in which those words were used, and assigns a code along with a degree of certainty for that code.

NLP is good for analyzing large amounts of information for relatively straightforward medical cases. It's very difficult to try and harness any kind of predictability in language.

Editor's note: This question was answered in a recent issue of For more information, click here.

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