Electronic Health Records have greatly benefited health care. However, the wide adoption of EHRs did not come without certain drawbacks, especially for providers. Do you remember what it was like to go to the doctor 15 years ago? You’d walk in and immediately see a lifetime supply of manila folders behind the front desk staff. When the provider entered the room, they were able to sit in front of you and have an engaging conversation. Today, a majority of providers are having to type into a computer in order to meet electronic documentation requirements. Although EHRs have propelled health care forward in many ways, unfortunately, they’ve added a new burden for providers: having to code from their patient visits with standardized code sets.
Providers are expected to document within different sets of billing and clinical terminologies. Simply put, these are standardized vocabularies that allow representation of the same health concepts between different health information systems. You can think of health care terminologies as the building blocks that support the entire health care documentation process. They allow patient data to be transferred in a way that can be understood and consumed universally, which is necessary not only for individual patient records but also for public health reporting, statistics, and billing.
You may be wondering: why is this a problem for providers? To dive in, let’s focus on two code systems often used by providers:
ICD-10 (International Classifications of Diseases, 10th Edition) is often used for the backbone of diagnoses. The issue is that the coding hierarchy was built for billers and therefore is not provider-friendly. A lot of the terms aren’t expressed in everyday provider language (ie - “myocardial infarction” instead of “heart attack”), and there aren’t enough codes to capture the specificity of many clinical concepts. In general, ICD-10 is appropriate to be used as the backbone for billing but lacks the specificity needed for clinical documentation.
SNOMED-CT (Systematized Nomenclature of Medicine – Clinical Terms) is a clinical term that includes diseases, clinical findings, etiologies, procedures, and health outcomes. It was the terminology required to meet Meaningful Use Stage 2 certification standards back in 2014 and is what providers typically use to document clinically in the EHR. Although this is a more comprehensive, clinical-based terminology, it still forces providers to document using the language of the code system rather than being able to document using their everyday language. There are several complexities to each code set - such as having to post-coordinate on a term to make it more clinically specific.
This is burdensome because providers are, on top of their growing list of patient responsibilities, now tasked with learning multiple coding languages - which was something that was previously handled exclusively by billers and coders. With the wide adoption of EHRs, it moved the clerical task of coding to the providers, which shows that EHR technology is not assisting the providers, but rather the providers are assisting the technology. Why make providers learn all of these different code languages instead of allowing them to document clinically in the way they were trained?
Thankfully, there are solutions that help to ease this new coding burden on providers. Here at pMD, we accomplish this on the charge capture side by making the diagnosis and charge lists extremely customizable - not only to each practice but down to the individual provider. We can rename ICD-10 and charge code terms based on the provider’s preference, float important terms to the top, and delete terms that are not necessary. By offering a highly customized pick list, we eliminate the need for providers to memorize multiple coding languages.
There are also clinical interface terminology solutions that serve as a bridge between code sets and providers. These companies offer expansive clinical vocabularies that have multiple synonyms and ways of documenting each term (ie - “type 2 diabetes,” “t2dm” and “diabetes, type II” would all be options for documenting the clinical concept of type II diabetes mellitus). They are very helpful to providers documenting in the EHR where more in-depth documentation is required. Overall, EHRs have helped propel health care forward, but pMD helps to take the coding burden back away from providers.
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