- Meaningful Use Stage 2, including Electronic Medication Administration Records
- ICD10, including clinical documentation improvement and computer assisted coding
- Replacement of all Laboratory Information Systems
- Compliance/Regulatory priorities, including security program maturity
- Supporting the IT needs of our evolving Accountable Care Organization including analytics for care management
One part that crosses the 5 work streams is how electronic documentation should support structured data capture for ICD10 and ACO quality metrics.
How are most inpatient progress notes documented in hospitals today? The intern writes a note that is often copied by the resident which is often copied by the attending which informs the consultants who may not agree with content. The chart is a largely unreadable and sometimes questionably useful document created via individual contributions and not by the consensus of the care team. The content is sometimes typed, sometimes dictated, sometimes templated, and sometimes cut/pasted. There must be a better way.
Imagine the following — the entire care team jointly authors a daily note for each patient using a novel application inspired by Wikipedia editing and Facebook communication. Data is captured using disease specific templates to ensure appropriate quality indicators are recorded. At the end of each day, the primary physician responsible for the patient’s care signs the note on behalf of the care team and the note is locked. Gone are the “chart wars”, redundant statements, and miscommunication among team members. As the note is signed, key concepts described in the note are codified in SNOMED-CT. The SNOMED-CT concepts are reduced to a selection of suggested ICD-10 billing codes. A rules engine reports back to the clinician where additional detail is needed to justify each ICD-10 code i.e. a fracture must have the specifics of right/left, distal/proximal, open/closed, simple/comminuted.
The following is a new process designed to improve the capture of data and create better work flows for coding.
Module 1 – disease specific templates
Module 2 – technology to capture free text and populate the templates i.e. my Wikipedia/Facebook concept describe above.
Module 3 – natural language processing to codify SNOMED-CT concepts
Module 4 – mapping of SNOMED-CT concepts to ICD10 codes
Module 5 – rules to ensure documentation is complete enough to justify the ICD10 codes
Industry leaders like Kaiser, Geisinger and Mayo are already working on elements of this approach. There will be challenges. They are:
1. Clinicians are not broadly trained in the use of SNOMED-CT. It may be that SNOMED-CT should be used for internal storage of structured data but only friendly plain text descriptions are displayed to users.
2. Will CMS, the Joint Commission, and malpractice insurers accept the concept of jointly authored care team notes?
3. Implementing all 5 applications/modules at once may be too much change too quickly, making the overall project high risk
4. Will SNOMED-CT map to ICD-10 cleanly enough to ensure neither upcoding nor downcoding, but “right coding”
5. Will companies be willing to create such modules/services at a time when few EHRs are likely to interface to them? As Meaningful Use Stage 3 is finalized, I expect some of this functionality to be required
We now have 15 months before ICD-10 compliance is required and complete documentation in support of the new codes must be available. The radical change must happen quickly in order to experience the full benefit. What are your thoughts?
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Author: John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician.
Phil C. Solomon is a healthcare finance, clinical documentation and revenue cycle BPO strategist with experience spanning two decades. Phil has expertise in the areas of revenue cycle optimization, clinical documentation improvement, healthcare technology integration and BPO outsourcing. He is the publisher of Revenue Cycle News, a healthcare revenue cycle blog and is a featured speaker at many HFMA, NAHAM and AAHAM healthcare educational conferences.