The electronic health record is at the heart of efforts to improve clinical documentation. One effort strives to get disparate EHR software programs—and the physicians using them—to encode problem lists in a common way.
This article appears in the March 2014 issue of HealthLeaders magazine.
With the October 1 activation date for ICD-10-coded payments and the end-of-year move to meaningful use stage 2, this will be a watershed year for clinical documentation improvement.
Technology is playing a big role in both efforts. To an unprecedented degree, and with significant cost and effort, the electronic health record is becoming the heart of clinical documentation improvement—prompting doctors to enter more specific diagnoses, reducing the need for labor-intensive coding, and propagating a common vocabulary between disparate care coordinators to enhance decision support.
"Clinicians are taking care of patients, doing their documentation as they always have, but interface terminology actually gives them phrases or other things that they can use, and those are mapped to SNOMED and often to ICD," says Rita Scichilone, who until recently was senior advisor for global standards at the American Health Information Management Association.
SNOMED CT—the Systematized Nomenclature of Medicine Clinical Terms—is required to be generated by EHRs in order to be certified under the meaningful use stage 2 program. "SNOMED CT is a terminology, actually the language of medicine, which makes it very different than a classification system" such as ICD-10, Scichilone says.
One of SNOMED CT's great benefits is it requires disparate EHR software programs—and the physicians using them—to encode problem lists in a common way, Scichilone says. Prior to the SNOMED CT requirement, EHR software supported a variety of encoding schemes, which often made interoperability and sharing of problem lists impractical.
"Clinical quality measures that CMS is developing are leveraging some of the SNOMED vocabularies to define the numerator and the denominator of a particular patient that has a particular kind of diagnosis or condition," says Doug Fridsma, MD, PhD, chief science officer and director of the office of science and technology in the Office of the National Coordinator for Health Information Technology.
"For example, if somebody has a fractured right leg, SNOMED would have three concepts—a right concept, a leg concept, and a fracture concept—and you'd put all three of those together to create the right leg fracture," says Fridsma. "ICD-10 will have a right leg fracture and a left leg fracture and a right leg fracture complex, so it has to have unique codes for each one of those things. SNOMED actually is designed a lot more in terms of how doctors and clinicians might think, and so they can kind of take the codes that represent the things that they care about—right leg fracture—click on those concepts, and it automatically then generates those three codes together to represent the diagnosis or whatever is there.
Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.