Standardization needed in CPR clinical terminology
Common definitions essential
The computerized patient record (CPR) is many things to many different health care professionals, and as the industry moves toward completely electronic health records, standardization is needed more than ever before.
"What’s happening in most health care facilities is they have grouper software systems that automatically group it to the DRG once they put codes and demographic information on patients," says Valerie Watzlaf, PhD, RHIA, associate professor for the HIM department of the University of Pittsburgh.
"The whole purpose is if you just used ICD-9 codes, there would be so much of the content that people would want from the electronic health record that would not be there," Watzlaf explains. "We’re looking at it in terms of getting data out to users, including physicians, nurses, researchers, HIM professionals, but it’s not necessarily linked to reimbursement."
According to preliminary results of a recent nationwide survey conducted by Watzlaf and colleagues, more than one-third of responding health care facilities said they were planning to install a computer-based patient record.
"Twenty percent are saying they have a CPR system fully in place, which is quite surprising," Watzlaf says.
Most of those who have a CPR system appear to be using a vendor system, with less than one-fifth reporting that they have developed their own system in-house, Watzlaf says.
Among the most common clinical terminology for creating CPRs, besides ICD-9-CM and CPT-4, are the SNOMED, Read Codes, and Uniformed Medical Language System (UMLS). The UMLS serves as a medical thesaurus with clinical terminology, Watzlaf says.
"It seems in general that SNOMED in all categories is doing well, although researchers say that none of the systems available are effective," Watzlaf adds.
For this reason, there are efforts under way to map SNOMED to the ICD-9 codes, so that the resulting system would be familiar to coders, Watzlaf says.
"SNOMED has always been a clinical terminology classification system used for coding diagnoses and procedures," Watzlaf says. "I don’t know that anyone has used that for reimbursement, so it will be nice to enhance it to be mapped to ICD-9 codes."
SNOMED began in 1965 as the Systematized Nomenclature of Pathology, an alphanumeric coding scheme. It was changed in 1977 to the Systematized Nomenclature of Human and Veterinary Medicine (SNOMED), which had an expanded alphanumeric coding scheme that included all terms related to diagnoses and procedures.
After several further evolutions, in 2000 it became the SNOMED Reference Terminology, which is a coded reference terminology implemented in the electronic health record, radiology, clinical lab, and surgical pathology. This year, the SNOMED Clinical Terms is under development, and includes the merger of the SNOMED RT with the Read Codes and a refinement of the mapping criteria to ICD-9-CM, Watzlaf says.
"In 1997, SNOMED had more than 150,000 terms that could be incorporated into database operations," Watzlaf says. "One thing the ICD-9 does too is collapse codes into unspecified categories, and so a lot of times it’s thrown in there, and you lose the specificity with those types of codes."
A chief advantage to SNOMED is that that it already collects more data than many other systems, Watzlaf adds. "If we want to move forward toward an electronic health record, we’ll need to be able to collect a lot more data, mine that data, and look at extensive amounts of information."
However, because the ICD-9 coding system is used so extensively in the United States, it’s important to have a CPR system that can be mapped to ICD-9 codes, and that’s where the latest version of SNOMED will be very helpful, Watzlaf says.
Besides creating a seamless transfer of data, an electronic health record should help improve clinical care, she notes.
For instance, a CPR will enable physicians typing in data about a patient to see text or pop-up boxes triggered by the particular data to remind the doctor to order a specific test, Watzlaf explains. "It all can be done very sophisticatedly with the CPR, and it’s not all that difficult to do." All that is required is for the CPR system to have some type of terminology to break down the data and then a standardization like ASTM standards, she says.
"If we can organize data and standardize it across many different systems within different health care facilities, then we have a longitudinal health record that could be very similar across facilities, and it will be more standardized to clinical content," Watzlaf says.