Opportunity Opens for Coders in the Digital World
You are in a position to safeguard accurate medical data capture within electronic exchanges.
By Michael Stearns, MD, CPC, CFPC
Health care organizations are encouraged by the U.S. government to accelerate their adoption of health information technology (HIT), including electronic health records (EHRs). There is significant evidence that improvements in health care’s quality and cost-effectiveness are tied to HIT use, and in particular, to discrete data. To be useful in clinical care, this information must be stored in the form of codes that accurately and completely represent clinical conditions, results, procedures, and devices. We’ll explore the emerging opportunities for coding professionals who are in a position to assist clinicians with an understanding of how to capture and use clinical code information.
Consider the Possibilities
There are three potential coding professional roles that are tied to the rapidly expanding role of HIT in clinical care. We’ll explore:
- how the information captured from EHRs can be coded accurately for clinical use
- how this information, used by clinical HIT systems, is designed to exchange data between health care organizations
- how this information is used by other clinical systems
- necessary quality controls to protect patients from medical errors related to inaccurate or incomplete information
Resource Tip: Other EHR opportunities for coding professionals, such as how they can help providers reduce their risk of a negative audit through calculating evaluation and management (E/M) codes can be found in the article “EHRs Pose Challenges, Provide Opportunities” of June 2009’s Coding Edge.
EHRs use templates or similar tools that often can store codified information, making it easy for clinicians to simply click on a clinical expression that automatically generates a code to represent that concept. This information is necessary to submit claims, but now it also will be used for clinical decisions.
Codified data is used within EHRs to support automated clinical decision support tools, such as when the patient has a disease that is a contraindication for use of a specific medication, and the EHR alerts the physician before the medication is prescribed. It also is used to manage patient populations by assessing what preventative interventions (e.g., immunizations) are needed, and compliance with treatment guidelines (e.g., blood pressure control). With a greater dependency on codified data for automated use in patient care, information stored as codes needs to be as accurate and complete as possible.
In most systems this information is stored as ICD-9-CM codes, which were not designed for use in clinical information systems and have the potential to introduce inaccuracies that could lead to patient safety issues. ICD-10-CM offers a number of advantages, but may have certain limitations related to its origins in ICD-9-CM.
To overcome these limitations, other terminologies, such as Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT®) will become more common in the near future. For example, the U.S. government already allows for the use of SNOMED CT® as an alternative to ICD-9-CM for the electronic submission of patient problem lists for data exchange. The World Health Organization (WHO) is considering altering the structure of ICD-11, slated for release in 2015, to better align more closely with SNOMED CT®’s features. Coding professionals will have the dual role of helping practices capture information in EHRs that meets both administrative and clinical needs. Knowing the challenges associated with ICD-9-CM, ICD-10-CM, and SNOMED CT® codified data capture within EHRs is a skill set in demand right now.
What the Future Holds
The next phase in the clinical data lifecycle is its submission to health information exchanges (HIEs). HIEs are networks that allow health care organizations to share information within communities.
Currently, the primary tool used to share clinical information is the Continuity of Care Document (CCD), which is a clinical summary of the patient’s problems, medications, allergies, recent labs, and other relevant information. It can contain codified or free text information; however, in the future codified data will largely replace free text. CCDs can be stored within the HIE and accessed by health care providers who have appropriate permission.
Data from multiple patients can be abstracted from CCDs and used for population health initiatives, such as how well providers are managing diabetic patients in a geographic region. For these key health care initiatives to be effective, the data submitted to an HIE must be as accurate and complete as possible. Coding professionals know the nuances of how codes represent clinical information, and have the opportunity to expand their role as data stewards as health care becomes increasingly dependent on information shared through HIEs.
Another role for coders will be to ensure the data received by an EHR from an HIE or another EHR is accurate and complete. This will become an important patient safety issue because clinical decisions may be made based on the accuracy of this information. For example, if a patient has been diagnosed with chronic pelvic pain, for which there is no specific ICD-9-CM code, the information may be received as the “closest match” ICD-9-CM code (e.g., 789.04 Abdominal pain left lower quadrant). Those without coding knowledge would have difficulty understanding how code description information might not be accurate or complete. Practices will need clinical data gatekeepers to prevent medical errors that could occur if inaccurate data is received and used by an EHR.
What You’ll Need to Know
As a coding professional, take advantage of emerging opportunities in health care and benefit from knowing how information is captured as codified data and used in EHRs, shared and used within HIEs, and imported and used by other systems. Getting to know SNOMED CT® and mapping efforts between ICD-9-CM, ICD-10-CM, and SNOMED CT® can make you more valuable to many health care organizations.
You have mastered converting clinical information into codified data, and HIT depends upon access to accurate and complete data stored as codes that can be easily processed and managed by computer systems. This has created a unique opportunity for you to play an essential role in improving the quality and efficiency of health care through the expanded use of information technology.
Knowing the challenges associated with ICD-9-CM,
ICD-10-CM, and SNOMED CT® codified data capture within EHRs is a skill set in demand right now.
Michael Stearns, MD, CPC, CFPC, is a board certified neurologist. He has 15 years of experience in clinical and academic medicine, and over 14 years of experience in HIT and has been a certified coding professional (CPC®) since 2006. Dr. Stearns served as the international director of SNOMED CT® during its formation. He has presented and testified at several national meetings on medical terminology, EHRs, coding, and genomic medicine. Dr. Stearns is the president and CEO of e-MDs, an EHR company, and the board president of the Texas e-Health Alliance, a non-profit policy and advocacy organization.