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ICD-10 and EHR Fuel Clinical Documentation Improvements

Scott Mace, for HealthLeaders Media, March 18, 2014

"It gives you a better chance to logically operate on that data in ways that others need to do things of a computing nature with that data," Hickman says.

Despite this, "the vocabulary that they use to express things is somewhat different than the vocabulary at my place, and, therefore, I have to always have my translation thing turned on inside my own head to figure out the differences. So yeah, all these vocabularies are intended to bring us to something in common in understanding," Hickman adds.

Hawaii Pacific Health, a nonprofit, four-hospital integrated healthcare provider, still relies upon an extensive physician coding group, but it utilizes tools built into its Epic EHR software to make it as easy as possible for the coding to occur, says Steve Robertson, executive vice president and chief information officer. "There's an ICD-10 diagnosis calculator where the physician enters the diagnosis, but if [the] ICD-10 terms are not quite specific enough, it'll prompt the physician to add a little bit more specificity."

Still, Robertson cautions that such computer-assisted coding technology remains somewhat unproven. "It's still somewhat new, and all these promises of improved productivity may be a pipe dream, depending on how well your engine has been tuned," he says. "We have bought a product from Dolbey and it is installed. We're in the process of doing the tuning, so it's still too early to say what kind of an impact it will have."

Other providers are pleased with the latest CDI improvements in the EHR software they are using. "It's all part of the doctor's work then, and the note and the description and the work that they've done in the earlier part of the documentation builds toward using an electronic and computer-based method, builds toward that final code, rather than the doctor having to initiate a whole separate part of engagement, which is just to do the coding," says Peter Plantes, MD, CEO of Christus Physician Group, which employs more than 150 physicians and other healthcare providers in family practice, internal medicine, pediatrics, OB-GYN, and other multiple medical and surgical specialties, such as orthopedic trauma and cardiovascular surgery. The group operates more than 70 medical clinics throughout Louisiana and Texas, and provides staffing for several hospital-based programs.

Christus uses athenahealth's EHR software across its approximately 70 outpatient clinics to generate appropriate SNOMED CT and ICD-10 codes, Plantes says. "It's much more accepted and much better appreciated than athena's prior internal tool for coding," he says. "If we had to do this all by intensive training alone, without the SNOMED tool, then the reliability [of] any individual physician through the manual method of what they used to do with ICD-9 would just not have worked at all. This is a huge step forward, and we are supplementing the tool with education."

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