In the days of pen and paper
Long before the creation of the electronic health record (EHR), physicians relied on the humble paper chart. With pen in hand, they documented each patient encounter in their own words, with their own abbreviations, in varying degrees of legibility, and then passed along the paperwork to the billing department to process. For some trained in this manner, there remains a longing for simpler times – for the days when one could tell a patient’s story without the constraints of a keyboard and coding dictionary. This nostalgia is often born from legitimate frustration with technology and the disruption of well-established clinical workflows.
EHRs, after all, were developed for billing and coding, not for meaningful clinical documentation. How physicians communicated and worked was not a primary concern for software designers since, at least initially, clinicians weren’t the EHR’s primary users. However, as EHR adoption gained momentum and use cases evolved, so too did the demands on clinicians. Soon enough, the art of telling a patient’s full story was supplanted by the stress of finding and memorizing standardized codes – an inefficient process that left the patient’s record incomplete and clinicians struggling to communicate in an unfamiliar tongue.
Searching for healthcare’s Rosetta Stone
The need to input alphanumeric codes into the EHR to describe patient encounters, problems, and procedures was challenging from the start. For many clinicians the process was unnatural and foreign, adding both time and frustration to their daily work. At the time, it wasn’t uncommon to see physicians carrying around stacks of index cards bearing the frequently used codes they needed for documentation. And, with patients queued in the waiting room, the search for the most accurate code often ended with clinicians choosing one that was “good enough.”
It quickly became clear that a bridge was needed to enable clinicians to “speak clinician” while using the EHR. Providers needed a tool that allowed them to document in detail and still get paid. They needed some sort of medical Rosetta Stone that could translate their everyday clinical language – essential for patient care and communication between providers – into standardized, administrative codes.
Today's history lesson: The Rosetta Stone
Long before the Rosetta Stone1 became synonymous with a language-learning software traded on the New York Stock Exchange, the famous stone slab, or stele, was used by the ancient Egyptians to announce that King Ptolemy V, who reigned from 204-181 BC, was supported by the priests of a certain temple in Memphis. The stele was discovered, quite by accident, by Napoleon’s army on July 15, 1799 as they dug a fort close to the town of Rashid (Rosetta) in the Nile Delta.
So what? Good question.
The key, for our purposes, is that the Rosetta Stone was written in three different scripts (Demotic, Ancient Greek, and hieroglyphs). Since the scholars studying the stele understood Ancient Greek, they were able to ‘crack the code’ to understand Egyptian hieroglyphics that had long been out of use and, as a result, undecipherable. The Rosetta Stone was like an ancient decoder pin that opened the door to a new and exciting understanding of Egyptian culture and language.
Decoding the language of healthcare
The solution to this problem came in the form of clinical interface terminology, or CIT. This software, which integrates into the EHR, “bridges the gap between information that is in the physician’s mind and information that can be interpreted by computer applications.”2 At its best, CIT empowers the clinician to use their own words, not codes, to document important information from a patient visit, while simultaneously handling the complex connections, or mappings, to clinical terms and codes behind the scenes.
Clinical Interface Terminology
The most effective clinical interface terminology solutions allow providers to use familiar terms, synonyms, and abbreviations to document patient problems and procedures. But the work doesn’t end there. In order to optimize billing and reimbursement, various codes from a number of standardized code systems may be required to capture the full patient condition. CIT addresses this need behind the scenes by mapping specific terms to multiple codes as necessary – saving time and improving accuracy. (The example below illustrates these connections for heart attack with ST elevation).
The foundational role of clinical terminologies
While the impact on clinicians may seem obvious, CITs create important ripple effects throughout the healthcare ecosystem. From the ability to secure the right reimbursement, to executing on population health programs, clinical terminology plays a pivotal, foundational role in a host of ways, four of which are touched upon below.
Precise documentation
Standardized code systems, which frequently omit important granular details like laterality and comorbidities, have never been sufficient for capturing clinical data. “[A]dministrative code sets were designed to either group diagnoses and procedures, or to contain broad categories with administrative technical terms with complex rules and guidelines.”3 Capturing the kind of detail required for truly meaningful documentation requires a different kind of tool: a new, clinically-oriented language for the EHR. Robust clinical terminologies are essential because they provide clinicians with a variety of terms to choose from when they notate a patient’s condition in the EHR. By allowing for the use of synonyms, acronyms, and abbreviations – not just alphanumeric codes – they give clinicians the freedom to select terms that are truly the best fit. Free to “type like they talk,” clinicians can build better, clearer, more accurate medical problem lists, which improves patient safety. And, comprehensive clinical terminology facilitates intuitive documentation with speed and accuracy. Without it, too much simply gets lost in translation.
Billing and reimbursement
As mentioned above, billing automation was the original motivation for the creation of EHRs, but as expectations increased for clinical use, the need for a solution that paired clinical terminology with code mappings became apparent. Also driving the creation of a Rosetta Stone-like solution was the growth in standardized coding systems such as ICD-10-CM, SNOMED CT®, and CPT®4, and the burgeoning volume of codes they contained. It is a trend that shows no sign of slowing, as illustrated by the leap from ICD-9-CM’s 13,000 codes to the more than 68,000 codes in ICD-10-CM.5
On the one hand, physicians simply couldn’t be expected to memorize thousands of diagnostic and procedural codes. On the other, the basic search functionality of EHRs was not adequate or reliable enough to connect the dots between clinical terms and billing codes. Beyond sheer volume, however, is the frequent need to update existing code sets and their corresponding maps to clinical terms since most standardized coding systems are updated at least once a year. This ongoing maintenance, which is central to CIT, ensures that the most current codes are readily available for clinical use, and when selected lead to more accurate reimbursements. In addition, connecting clinical terms to the right codes facilitates faster pre-authorization, which, in turn, speeds patient care.
Interoperability
The ability to share healthcare data is predicated on a number of interrelated factors. Among them is the foundation of a common ‘language’ in which to communicate. Without a vast repository of clinical terms that then connect to standardized codes, information becomes fragmented. Incomplete. As data is exchanged between multiple sources, such as healthcare providers and health information exchanges, what may start off as robust documentation stands little chance of retaining its specificity if there is no way to communicate details outside of billing codes.
Due in part to the proliferation of new sources of patient data – such as wearables, gene sequencing, and patient portals – the volume of healthcare data is increasing at a staggering rate. In fact, between 2020 and 2025, the total amount of global healthcare data is forecasted to grow from 2,300 to 10,800 exabytes.5 In order to effectively normalize – or, standardize – all of this data and meet the challenges of interoperability, we must start with the common understanding made possible by an extensive and definitive clinical terminology.
Population health and analytics
Successful population health initiatives begin with the identification of precise patient cohorts. Value sets are frequently used to find populations of interest, but if these sets are created using only standardized coding systems, accuracy suffers. The coarseness and complex hierarchies of these codes often lead to mistaken omissions and inclusions, which then muddy the makeup of a given cohort.
Value sets based upon the fundamental building blocks of precisely-mapped terminology make it possible to identify patient populations with greater accuracy and granularity. Since CIT connects carefully defined clinical terms from a nuanced and a rich library of synonyms and then maps them to the appropriate codes, patient cohorts gain a higher degree of sensitivity and specificity – resulting in more trustworthy analytics and successful outcomes.
INSIGHT BRIEF
Accurate value sets:
The basis for clinical initiatives and targeted analysis
Conclusion
The use of clinical interface terminology has become almost as prevalent as EHRs themselves. While the quality of these solutions varies based upon vendor, architecture, and the depth of integration, the value they provide across the continuum of care is undeniable.
From small practices to the largest health systems, comprehensive terminologies make tasks and workflows such as clinical documentation, billing, and data analysis easier, faster, more accurate, and consistent. But at the most basic level, CIT makes these things possible. One need only imagine their EHR without it to begin to understand its vast reach and impact.
Clinical interface terminology serves as a common thread that enables connections and communication between countless parts of the digital healthcare ecosystem. Much like the Rosetta Stone, it opens doors to greater understanding and collaboration. It bridges a multitude of divides and is the technological backbone of individual patient encounters as well as vast studies of millions of individuals.
But in contrast with the ancient stele, clinical terminology and mappings are constantly changing; adapting to include new codes, medications, procedures, and treatments. Far from set in stone, this technology is both fluid and foundational – a powerful driving force behind the evolution of modern medicine, the EHR, and heath IT as a whole.
To learn what makes IMO Health the industry leader in clinical terminology, click here. Or if you’d like to schedule a demo with one of our experts, click here.
References
1The British Museum. Everything you ever wanted to know about the Rosetta Stone. 14 July 2017. Accessed 13 October 2020 via: https://blog.britishmuseum.org/everything-you-ever-wanted-to-know-about-the-rosetta-stone/
2Kanter AS, Wang AY, Masarie FE, Naeymi-Rad F, Safran C. Interface terminologies: bridging the gap between theory and reality for Africa. StudHealth Technol Inform. 2008;136:27-32. PMID: 18487703. Accessed 13 October 2020 via: https://pubmed.ncbi.nlm.nih.gov/18487703/
3Bronnert J, Masarie C, Naeymi-Rad F, Rose E, Aldin G. Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible. AHMIA HIM Body of Knowledge. Accessed 13 October 2020 via:https://library.ahima.org/doc?oid=105588#.X16LeGhKh-Pa
4ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification, and is used primarily for medical diagnoses. CPT stands for Current Procedural Terminology and is used for the documentation of medical procedures. SNOMED CT stands for Systematized Nomenclature of Medicine – Clinical Terms, and is the international standard for the capture, storage and sharing of clinical data.
5LEK Consulting. Tapping Into New Potential: Realising the Value of Data in the Healthcare Sector.
Accessed 1 October 2024 via: https://www.lek.com/insights/hea/eu/ei/tapping-new-potential-realising-value-data-healthcare-sector
