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Brainstorming about the future of clinical documentation

6:00 am by | 0 Comments


In 2013, I'm focused on 5 major work streams:

* 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
I've written about some of these themes in previous posts and each has their uncharted territory.

One component that crosses several of my goals 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.

I recently attended a two day retreat to brainstorm about novel approaches to clinical documentation.

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.  

You can imagine that the moving parts I've described are modular components provided by different companies via cloud hosted web services (similar to the decision support service provider idea)

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

We've been speaking industry leaders such as m*modal, 3M, and Optum about these ideas.

Early adopters including Kaiser, Geisinger and Mayo are already working on elements of this approach.

However, there are challenges.

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 have 22 months before ICD-10 compliance is required and complete documentation in support of the new codes must be available. We need to work fast.   Tomorrow we have an internal conference call to plan next steps - what module or modules do we work on first?   We have companies interested in partnering with us on Modules 2 and 3.   The National Library of Medicine's VSAC is developing module 4.

I welcome your advice - have you discovered emerging products that might be useful for our exploration?

Have you considered how to take your clinical documentation to the next level?

I look forward to the adventure ahead.

Copyright 2014 MedCity News. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Dr. John D. Halamka

By Dr. John D. Halamka

Dr. John D. Halamka is chief information officer and dean for technology at Harvard Medical School who writes at Life as a Healthcare CIO.
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