Imagine spending an entire day seeing patients, dedicating all your energy to treating their ailments. Now, picture yourself at the end of that long day, not heading home to unwind, but instead facing tedious hours of documentation and coding.
This is the reality for many physicians, a reality that can lead to burnout and even diminished care quality.
Athenahealth, a provider of cloud-based services and point-of-care mobile applications, recently underscored this issue in the podcast episode, Reducing coding tasks for overworked physicians with “Enhanced Diagnosis.”
In it, Dr. Nele Jessel, Chief Medical Officer at athenahealth, details a new Enhanced Diagnosis feature that leverages IMO Health clinical terminology and aims to reduce the administrative burden on clinicians.
Physicians are not coders by trade
Physicians enter the medical field to treat patients. Yet, they are increasingly required to navigate complex code systems like ICD-10-CM and SNOMED CT® at the point of care, while capturing the appropriate specificity.
As Jessel explains in the podcast, “The challenge is today that neither SNOMED nor ICD-10 are particularly clinician friendly. So, it can actually be challenging to find a SNOMED diagnosis that captures the clinical intent of the provider.”
The inability of major coding sets to communicate between one another also puts a huge strain on physicians and results in “pajama time,” or documenting off hours.
“If conditions do not accurately capture the severity of illness, meaning all diagnoses that their patient has, the cost predictions can be wildly off, and the patient’s care will cost more than anticipated, which then will lead to a potential financial loss for both the payer and the clinician or medical group,” Jessel says.
Building a bridge between clinical documentation and coding
While coders and physicians have distinct jobs, they do share common ground: the need for reliable, comprehensive terminology content.
To that end, athenahealth has introduced Enhanced Diagnosis, a tool designed to simplify the coding process and reduce the administrative load on physicians. This feature bridges the gap between the clinical and administrative worlds by offering a more intuitive, clinician-friendly system for capturing diagnoses with the highest level of specificity.
“We are focused on adding layers of intelligence and efficiencies to our application that will decrease the documentation administrative burden and really allow clinicians and care teams to return their focus to patient care,” Jessel explains.
One key layer of this intelligence is IMO Health’s clinical terminology.
“For our new enhanced diagnosis search, we leverage terminology from IMO Health,” Jessel says in the podcast. “IMO [Health]’s terminology allows providers to use clinical language for documentation on the patient chart while standard code sets leveraged across the healthcare industry for billing, data exchange, and reporting purposes are managed in the background.”
“What’s really cool about our new implementation,” she says, “is that we now receive diagnoses in real time from IMO [Health], meaning clinicians always have access to the latest diagnoses and codes, which reduces the risk of selection of outdated diagnoses or ICD-10 codes.”
Most importantly, Jessel says, this new diagnosis feature will ensure that all applicable billing codes are supported by the clinician’s diagnostic statement.
For our new enhanced diagnosis search, we leverage terminology from IMO Health. [Their] terminology allows providers to use clinical language for documentation on the patient chart while standard code sets leveraged across the healthcare industry for billing, data exchange, and reporting purposes are managed in the background.
A brighter future for providers
For athenahealth, this new feature represents a substantial step forward in reducing the administrative burdens that plague most clinicians and contribute to burnout.
While some diagnoses may require a few extra clicks due to the intricacies of ICD-10 coding rules, “the benefits of improved coding automation should more than outweigh this and will furthermore position all clinicians for success in the ongoing transition from fee-for-service to value-based care,” Jessel says.
According to athenahealth, this guided diagnosis workflow will be available to all athenaOne users by 2025.
Curious how you too can integrate IMO Health clinical terminology into your EHR to reduce clinicians’ “pajama time” and enhance care? Learn more here.
SNOMED and SNOMED CT are registered trademarks of SNOMED International.
