Provider-Friendly Terminology Speaks the Language of Quality and Safety
November/December 2011
Medical Terminology Management
Provider-Friendly Terminology Speaks the Language of Quality and Safety
As a practicing physician, my peers often ask me what I do in the technology arena. When I reply, “standardization or medical terminology management,” I’ve usually lost them. And at its core, the goal of standardization really is not to complicate matters for physicians and other clinicians. Provider-friendly terminology (PFT) is an example of the kind of standardization our industry needs. PFT is designed to accommodate the existing workflow and preferred terminology of clinicians so they can maintain their productivity and even improve the quality and safety of the care they provide, while complying with the latest regulations without missing a beat.
There are currently two major trends in healthcare driving the need for PFT to foster quality care and patient safety. The first is the transition from ICD-9-CM to ICD-10-CM. The second is adopting stage I and subsequent stages of Meaningful Use in order to qualify for reimbursement for implementation of electronic health records (EHRs) under the federal HITECH Act. Both trends aim to improve the granularity of information we capture about patients, to improve the quality of care both for individual patients and various populations, and to facilitate the development of evidence-based care. But what if this more detailed information isn’t accurate when captured in the patient record or, even worse, isn’t captured at all?
Here is how that could happen: many clinicians report diagnoses, notes, procedures, and findings in non-standardized language. Renal failure syndrome may be written in numerous forms such as RF, kidney failure, or failure of the kidneys. Computed tomography result abnormal could be interpreted as abnormal CAT scan result, abnormal CT result, computerized axial tomography result abnormal, CT scan result abnormal, and so on. The challenge for clinicians as they use EHRs is to select the right problems and procedures to record electronically without having to independently choose an ICD-10-CM, ICD-9-CM, and a SNOMED CT® code. ICD-10-CM itself explodes to a choice of 90,000, and SNOMED CT has a similar number of choices. If clinicians become so frustrated that they simply choose “unspecified problem,” we’ve negated the benefits of this increased information granularity. Furthermore, forcing providers to modify how they report on the care they deliver to accommodate pre-determined code sets only creates entrenched resistance that slows EHR adoption.
Other possibilities for error stem from laboratory results. Labs tend to have local terminology—that is, they often report using local proprietary codes instead of following a standardized approach. Using current technology such Health Language’s LEAP (Language Engine Access Portal) tool, these local lab codes are mapped to LOINC, the universal code system for identifying laboratory and clinical observations, which is required under Meaningful Use criteria.
Using Clinician Codes for Improved Safety
With PFT, instead of expecting clinicians to adapt their language to conform to the codes and problem lists, the codes and lists adapt to the clinicians. PFT is based on SNOMED CT, the most widely used clinical code set, ICD-9-CM, and ICD-10-CM, and includes thousands of abbreviations, colloquialisms, and synonyms. Mapping SNOMED CT to administrative standards such as ICD-10 allows physicians to stay in their comfort zone and continue using their preferred terms and abbreviations when documenting their diagnoses and procedures. In addition to standardizing clinical terms, these terms are also automatically converted into the appropriate standardized billing codes, enhancing reimbursement without requiring clinicians to learn codes that they shouldn’t have to know. Clinicians can record their problems electronically once using PFT and HLI records SNOMED CT codes, ICD-9-CM, and ICD-10-CM codes.
The language engine fueling PFT creates rules to help physicians and coders get to the most specific and billable code—all while using the same words they are used to, and the EHR can automatically and seamlessly accommodate the rules. Even the mountains of historical data already coded to different terminologies can be easily mapped to any new coding standard.
PFT also simplifies the process of creating and updating problem lists—a key component of Stage I Meaningful Use criteria. With a coded problem list that incorporates the common terms and abbreviations and valuable electronic tools that make it possible for clinicians to continue documenting the same way they did when writing in a paper chart, clinicians are far more likely to transition to an EHR. I know from my personal experience of transitioning from paper to an EHR, that I write things in the chart that are not captured in the EHR. For instance, too often, free text from physician dictation, which contains some of the most useful information from a patient encounter, can’t be captured as a dynamic data field. However, there is language engine technology that enables the meaningful information found in free text to be standardized into appropriate codes so it can be automatically entered in an EHR. This capability to electronically capture meaningful information and code to standardize medications and diagnosis improves patient safety and the ability to take care of patients.
Simplifying Compliance for Quality Measures
An added value of having implemented a robust language engine is that it helps simplify compliance with Centers for Medicare and Medicaid Services (CMS) quality measures, Physician Quality Reporting System (PQRS) reporting and pay-for-performance requirements by incorporating and updating more than 100 key clinical and administrative measures that impact hospitals and physicians. This use of the language engine enables data to be captured in a structured way for outcomes research, which is essential for complying with these requirements. PFT can easily perform the standardization and mapping needed to arrive at actionable analytics for these purposes.
And don’t forget Accountable Care Organizations (ACOs). This new healthcare delivery model can also benefit from the standardization offered by PFTs. Healthcare providers—primary care physicians, specialists, hospitals, home healthcare—are banding together to collectively improve the care and safety of Medicare patients while keeping costs down. In turn, doctors and hospitals are financially rewarded. PFT provides the information in a codified way and inputs the data in a streamlined fashion, so that patients have access to a coordinated team for better care.
So the next time you hear the term “standardization,” just think, “simplification.” We’re working behind the scenes to codify information so that physicians and other clinicians can continue to work the way they are accustomed to—with all the benefits of achieving Meaningful Use and ICD-10 compliance and providing the highest level of quality and safety to patient care. PFT and other embedded tools can speed adoption of technology such as the EHR, and the industry will win with easier access to patient information, increased quality, decreased lengths of stay, and increased revenue.
Brian Levy is chief medical officer and senior vice president at Health Language. Levy, who is also a practicing hospitalist, has served as co-chair of CCHIT’s Advanced Interoperability Workgroup, and as a member of the IHTSDO SNOMED CT Implementation Workgroup and the Scientific Advisory Board for the Cleveland Clinic. He is a frequent presenter at industry conferences and tradeshows and has authored numerous articles for key trade publications. Levy may be contacted via email at Brian.levy@healthlanguage.com.