Special AHIMA Edition September 2013

Terminology Tools Help Providers Meet Initiatives
By Brian Levy, MD
For The Record
Vol. 25 No. 13 P. 8

The health care industry faces a critical question on semantics. As meaningful use converges with ICD-10 and the evolving performance-based revenue landscape, one important issue for HIT vendors and providers alike is the need for a common medical vocabulary.

It’s no secret that the complexities associated with translating disparate clinical terms between HIT systems have been a barrier to interoperability. It will take coherency and consistency of language to support the kind of real-time sharing of patient information needed to achieve the aggressive quality expectations laid out in federal initiatives. This effort requires that information be mapped and linked to a standard terminology that can be understood universally across the care continuum.

Using SNOMED CT has been identified as an important standard to achieving meaningful use’s information-sharing goals as well as an effective tool for bridging to ICD-10. Now, as a stage 2 requirement for capturing problem lists, SNOMED conversion is becoming a priority component of the already complex, resource-strapped HIT strategy for many health care organizations.

As they consider efficient and effective approaches to compliance, providers first need to assess the terminologies currently used to capture problem lists and diagnoses. Equally important is analyzing how those terminologies may affect ongoing analytics and reimbursement as well as how to leverage the full benefits of SNOMED in meeting the bigger picture of meaningful use and ICD-10.

Advancing Problem Lists
Problem lists are not new to health care. Before EHRs, these critical patient care tools were maintained in the front of patient charts and updated manually as changes or additions were made to diagnoses. As patients move within an organization or from one provider or care setting to another, the goal always has been to provide an accurate synopsis of all current issues and conditions impacting care.

While the introduction of EHRs has provided an efficient way to capture problem lists, the industry has faced ongoing challenges to electronically capturing the information needed to create a thorough and accurate picture of a patient’s issues. Much of the difficulty can be traced to the need for a standardized terminology.

EHR vendors addressed this issue early on by using the ICD-9 coding system as the basis for creating a standard terminology for problem lists. Because ICD-9 is principally for providing diagnosis codes for billing, its reliability has not consistently produced the detail needed for a comprehensive problem list.

While the move to the ICD-10 coding system promises to provide the specificity needed for more accurate billing, industry experts realize it still will not be conducive to producing the data needed for a useable problem list. For example, an ICD-10 code for billing may read “heart failure, unspecified” or “other specified heart block,” limiting the comprehensive nature of information provided to a clinician trying to understand a patient’s true condition.

Problem lists—when compiled accurately and thoroughly—have the potential to immediately align multidisciplinary treatment efforts as patients are triaged from unit to unit or provider to provider. In an effort to make problem lists more effective and usable as a clinical decision-support tool, stage 2 meaningful use requires that health care organizations leverage the SNOMED comprehensive clinical terminology system for documenting problem lists, family history, drug/allergy reactions, smoking status, and hospital procedures.

Owned and maintained by the Denmark-based International Health Terminology Standards Development Organisation, the SNOMED CT code set, which has been around since 1965, has a long track record of success and international acceptance. The system enables computers to understand medical language and act on it through a large set of concepts and descriptions representative of many standard industry terminologies.

Computer-readable numeric strings that can be translated into numerous human-readable descriptions represent SNOMED CT concept codes. For example, a number representing the common cold may be linked to descriptions such as common cold, acute coryza, acute infective rhinitis, cold, or head cold. A hierarchical system organizes the concepts into multiple levels of granularity, and a relationship component links key concepts.

Currently, SNOMED CT has more than 311,000 concepts, almost 800,000 descriptions, 19 hierarchies, and more than 1 million relationships, providing the clinical detail necessary for appropriate care while omitting irrelevant billing information. Subsets are offered to narrow the set of codes based on provider need, and national extensions can be accessed for even greater detail.

Efficient, Effective Conversion
While SNOMED CT offers great potential for aligning providers and health care organizations with meaningful use and health information exchange goals, the conversion process can be daunting, especially when weighed against the many other HIT initiatives competing for time and resources. By providing maps between ICD-9 or ICD-10 and SNOMED, terminology conversion tools can ease the burden.

These provider-friendly terminology tools can be leveraged to decrease clinician time spent searching for the right codes for problem and billing lists. Physicians can search for the terms they are accustomed to using in the paper record, thus enhancing productivity and allowing the focus to remain on patient care. Behind the scenes, these terminology tools convert the terms to the best SNOMED CT and ICD-9/10 codes. When ICD-10 requires additional documentation details, such as the laterality of an injury or the type of fracture, these tools can prompt for such information to ensure proper reimbursement.

As providers and organizations leverage the efficiencies and benefits of terminology conversion tools, they can share information and enable interoperability with other systems.

It often will make sense for organizations to incorporate the SNOMED CT project into ICD-10 implementation strategies because the two terminologies will need to be used concurrently. For example, the more advanced conversion tools allow for ICD-10 codes to be dragged from an electronic superbill to the problem list and automatically translate them to SNOMED CT. Seamlessly mapping clinical terms among ICD-9, ICD-10, and SNOMED CT boosts revenue cycle efficiency and accuracy by eliminating productivity losses associated with trying to identify the correct code from among ICD-10’s expansive options.

Health care organizations also have the option to utilize terminology conversion technology to enhance data mining and analytics. Automatically mapping preferred terms to the correct standardized codes simplifies the capture, analysis, and exchange of information that will be needed to successfully navigate the business intelligence and reporting mandates of new treatment and financial models, such as pay for performance, value-based reimbursement, accountable care organizations, and patient-centered medical homes.

The Bigger Picture
The ability to capture meaningful use incentives and avoid federal penalties is a driving force behind SNOMED CT conversion. And while the process of maintaining separate code sets is creating a temporary headache for many organizations, the reality is that the improved granularity of information will help the industry meet patient population care management, operational efficiency, and reimbursement goals.

A great deal of focus currently is being placed on greater specificity, motivating health care organizations to implement documentation improvement programs. Provider-friendly terminology tools alongside advanced terminology conversion technology enable providers to identify and use the specificity needed to meet this objective.

Compliance with federal initiatives is imperative, but more importantly, leveraging the advantages of a comprehensive and standard terminology such as SNOMED CT serves the best interests of patients. When providers can capture the full patient picture on a problem list, appropriate treatment can be initiated early, improving the chances of better outcomes.

As the industry moves to the unified use of SNOMED CT for problem lists and ICD-10 for diagnoses, health care organizations will be better positioned to achieve stage 3 meaningful use requirements as well as other initiatives.

— Brian Levy, MD, is senior vice president and chief medical officer for Health Language.