Take a moment to reflect on clinical documentation practice over the past decade. A tremendous amount of progress has been made advancing the capture, analysis and distribution of information, and while room exists for improvement, we've come a long way from hand-written notes tucked inside paper charts. Yet there's a real risk in getting caught up by the mechanics and inefficiencies of some of the tools electronic health record technologies offer physicians to facilitate the retrieval and input of information while creating their clinical documentation.
Structured templates and data access features designed to capture the elusive but necessary coded elements for downstream reimbursement and reporting requirements can lead to some rather undesirable results when it comes to the quality and usability of documentation by anyone on the care team who is trying to understand what's really happening with a patient. Such information is clinically accurate, but lacks expression and the essence of what's important to each patient. So what does telling the patient's story have to do with preparing for ICD-10? Everything.
High-quality clinical documentation is the key driver for the financial, clinical and business decisions that healthcare organizations make every day. And as such, clinical documentation, and by extension physician workflow, are the focal point for change as the use of structured templates and coded problem lists become required to represent the granularity of detail necessary for proper coding in ICD-10. The current code set of approximately 18,000 codes will expand to over 140,000 when ICD-10 is in full swing, and much of the impact will be targeted on the need for additional detail in clinical documentation.
Equally, if not more important, is the need to capture the patient's story, best accomplished through narrative, unstructured text that allows the physician to clearly communicate to other members of the care team the circumstances surrounding the reasons why the patient is receiving care. So as we prepare to face the additional wave of changes that ICD-10 will require of physicians as they enter their documentation, how can we keep the focus on the patient and preserve the free flowing physician narrative while at the same time extract the details required for coding? The answer lies with the innovative use of technology.
Applications such as computer-assisted coding powered by clinical language understanding technology, also referred to as natural language processing, have emerged as automated solutions for extending the ability of clinical documentation improvement specialists to analyze narrative text and recall the volume of information required to support proper coding in the ICD-10 environment. Much of the literature and resources you will find today stress the importance of building a strong CDI program with an emphasis on providing tools and guidance for CDI specialists and coders to help prepare. Organizations such as the American Health Information Management Association, Healthcare Information Management Systems Society and Healthcare Financial Management Association acknowledge a recent study conducted by Nachimson Advisors, LLC, which estimates that the move to ICD-10 will increase documentation queries to physicians by about 15-20 percent with only minimal reduction over time. That means the current query rate to physicians for additional information, which currently occurs with about 40-50 percent of cases will increase to 70-75 percent when ICD-10 is implemented, and only decrease to 60 percent permanently. Such innovative technology can and should be included as part of your organization's approach to ICD-10 preparedness, but consider how similar assistive technology can be applied to start at the source of the documentation — the physician.
Physician acceptance of new technology is highly influenced by the perception of that technology as being helpful, improving efficiency and effectiveness and its smooth integration into existing workflow. The convergence of such advanced technologies as speech-enabled dictation and CLU technology offer the opportunity to allow physicians to continue dictating in their preferred workflow, both structured and unstructured information into the note, while automating the analysis and extraction of details to support financial, clinical and business decision making.
Starting at the source, physician documentation, a computer-assisted physician documentation solution powered by CLU offers the opportunity to analyze narrative text while the physician is documenting and draw attention to areas that may be missing specificity or are unclear, allowing the physician to make corrections midstream, generating a higher quality document which will facilitate coding that better reflects the level of care provided and ultimately more appropriate reimbursement.
Many of the common queries that are processed manually today by CDI specialists can be automated in this fashion, extending the CDI specialist's ability to cover more cases or look for additional sources of improvement. And by automating queries while the physician is documenting, the physician would be able to reflect and adjust on the fly, bringing the workflow much closer to their clinical thought process than traditional method manual query methods which come to the physician after a CDI specialist has reviewed the documentation. The current manual method of CDI specialist review and communication back to the physician limits beneficial physician documentation pattern modification in the long run, due to systematically delayed feedback. However, real-time feedback to physicians using technologies such as computer-assisted physician documentation and CLU can make physician documentation practice modification a reality, which will more quickly assist those providers and organizations achieve successful transition to the more stringent ICD-10 arena.
By keeping the focus on the patient narrative, such innovative use of technology allows the physician to continue uninterrupted in their documentation workflow. In this way physicians are empowered to tell the patient's story while still capturing the necessary details required for appropriate analysis and coding of information as a seamless approach to preparing for ICD-10.
Reid F. Conant, MD, FACEP is CMIO of Tri-City Emergency Medical Group in Oceanside, Calif., and president of Conant and Associates, and physician advocate for Nuance Communications, Inc.
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Structured templates and data access features designed to capture the elusive but necessary coded elements for downstream reimbursement and reporting requirements can lead to some rather undesirable results when it comes to the quality and usability of documentation by anyone on the care team who is trying to understand what's really happening with a patient. Such information is clinically accurate, but lacks expression and the essence of what's important to each patient. So what does telling the patient's story have to do with preparing for ICD-10? Everything.
High-quality clinical documentation is the key driver for the financial, clinical and business decisions that healthcare organizations make every day. And as such, clinical documentation, and by extension physician workflow, are the focal point for change as the use of structured templates and coded problem lists become required to represent the granularity of detail necessary for proper coding in ICD-10. The current code set of approximately 18,000 codes will expand to over 140,000 when ICD-10 is in full swing, and much of the impact will be targeted on the need for additional detail in clinical documentation.
Equally, if not more important, is the need to capture the patient's story, best accomplished through narrative, unstructured text that allows the physician to clearly communicate to other members of the care team the circumstances surrounding the reasons why the patient is receiving care. So as we prepare to face the additional wave of changes that ICD-10 will require of physicians as they enter their documentation, how can we keep the focus on the patient and preserve the free flowing physician narrative while at the same time extract the details required for coding? The answer lies with the innovative use of technology.
Applications such as computer-assisted coding powered by clinical language understanding technology, also referred to as natural language processing, have emerged as automated solutions for extending the ability of clinical documentation improvement specialists to analyze narrative text and recall the volume of information required to support proper coding in the ICD-10 environment. Much of the literature and resources you will find today stress the importance of building a strong CDI program with an emphasis on providing tools and guidance for CDI specialists and coders to help prepare. Organizations such as the American Health Information Management Association, Healthcare Information Management Systems Society and Healthcare Financial Management Association acknowledge a recent study conducted by Nachimson Advisors, LLC, which estimates that the move to ICD-10 will increase documentation queries to physicians by about 15-20 percent with only minimal reduction over time. That means the current query rate to physicians for additional information, which currently occurs with about 40-50 percent of cases will increase to 70-75 percent when ICD-10 is implemented, and only decrease to 60 percent permanently. Such innovative technology can and should be included as part of your organization's approach to ICD-10 preparedness, but consider how similar assistive technology can be applied to start at the source of the documentation — the physician.
Physician acceptance of new technology is highly influenced by the perception of that technology as being helpful, improving efficiency and effectiveness and its smooth integration into existing workflow. The convergence of such advanced technologies as speech-enabled dictation and CLU technology offer the opportunity to allow physicians to continue dictating in their preferred workflow, both structured and unstructured information into the note, while automating the analysis and extraction of details to support financial, clinical and business decision making.
Starting at the source, physician documentation, a computer-assisted physician documentation solution powered by CLU offers the opportunity to analyze narrative text while the physician is documenting and draw attention to areas that may be missing specificity or are unclear, allowing the physician to make corrections midstream, generating a higher quality document which will facilitate coding that better reflects the level of care provided and ultimately more appropriate reimbursement.
Many of the common queries that are processed manually today by CDI specialists can be automated in this fashion, extending the CDI specialist's ability to cover more cases or look for additional sources of improvement. And by automating queries while the physician is documenting, the physician would be able to reflect and adjust on the fly, bringing the workflow much closer to their clinical thought process than traditional method manual query methods which come to the physician after a CDI specialist has reviewed the documentation. The current manual method of CDI specialist review and communication back to the physician limits beneficial physician documentation pattern modification in the long run, due to systematically delayed feedback. However, real-time feedback to physicians using technologies such as computer-assisted physician documentation and CLU can make physician documentation practice modification a reality, which will more quickly assist those providers and organizations achieve successful transition to the more stringent ICD-10 arena.
By keeping the focus on the patient narrative, such innovative use of technology allows the physician to continue uninterrupted in their documentation workflow. In this way physicians are empowered to tell the patient's story while still capturing the necessary details required for appropriate analysis and coding of information as a seamless approach to preparing for ICD-10.
Reid F. Conant, MD, FACEP is CMIO of Tri-City Emergency Medical Group in Oceanside, Calif., and president of Conant and Associates, and physician advocate for Nuance Communications, Inc.
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