5 pluses of standardized coding
Billions of tax dollars are being invested in the healthcare sector in the name of getting providers moved from paper to electronic records. But while updating hardware and implementing software programs are perhaps the most visible elements of the digital transition, an equally important shift is happening more or less behind the scenes in the world of coding.
That ongoing and unseen project revolves around the development and implementation of code standardization programs that increasingly ensure that a doctor’s entry in one EHR will make sense to providers, researchers and policymakers regardless of where and how they access it.
As Brian Levy, MD, senior vice president and CMO of Health Language, a coding software provider, recently explained, the basic mission of code standardization programs “is to ensure that the clinician doesn’t have to worry about code selection.”
[See also: AHIMA calls for coding guidelines.]
Codes, of course, such as the ICD series, have been around for decades, but Levy said efforts to ensure standardization essentially took off with the introduction of the HITECH Act.
“Even doctors who’ve been using some form of electronic health records have been recording things with words,” he said, and those words often meant different things depending on the doctor or organization.
Now, however, that’s changing rapidly, and Levy sees a number of benefits resulting from the coding standardization that is rapidly spreading across the healthcare sector:
- Interoperability - This much-discussed goal is perhaps the most obvious of the potential benefits, in that coding that is used across different software systems will greatly facilitate the sharing of patient information regardless of how or where that information is accessed.
- Patient reporting - According to Levy, the move toward “pay for performance” payment models is going to bring the demand for in-depth analytics to a whole new level. For example, assessing outcomes across specific populations -- think diabetes patients, for instance -- requires standard codes that enable providers to look across an array of different data sets.
- Clinical decision support - “In the old days,” Levy said, “if I wanted to look up information on atrial fibrillation, I had to go to a medical library and look it up in a book. Now, I want that information to be readily available in my EMR. Standardization will greatly facilitate that process.”
- Workflow improvement - Currently, Levy said, it still takes many providers longer to enter information into an EMR than to write that same information into a chart. The standardization of coding, including the use of synonyms that providers can use that are automatically converted to code, with help expedite documentation over time.
- Patient access to information - Patients aren’t generally brought into conversations about interoperability, but Levy suggested that there is an obvious connection between the ease and facility with which data is recorded and the ease and facility with which patients can subsequently access it.
[See also: Survey shows uncertain future for ICD-10.]
As Levy sees it, the best days of standardization, so to speak, still lie ahead. “Stage 2 of meaningful use is where standardization requirements are really being ramped up,” he noted, with Stage 3 expected to take even longer steps down the road to the days when patient information is easily recorded and shared.