If you think getting standard medical terminology hardwired into EHR systems is simple, just ask the hundreds of...
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Pennsylvania men whose patient records indicated they smoked while pregnant.
Those patients, served by the University of Pittsburgh Medical Center (UPMC), got caught in a quandary of words because of the vagaries of insurance coding and the different vocabularies used in five separate EHR installations (three from Cerner Corp., one from Allscripts-Misys Healthcare Solutions Inc. and one from Epic Systems Corp.).
When UPMC leaders decided to standardize on one vocabulary set, they discovered patient records that had men who smoke mapped incorrectly to the reimbursement code for “maternal smoking disorder.”
That’s the type of problem Dr. William Hogan and registered nurse Debra Konicek set out to fix by implementing SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) in UPMC’s EHR systems.
The health system is on the vanguard of a national movement, because adoption of SNOMED CT is required of all health care providers by 2015 in order to qualify for meaningful use certification. Currently, most providers use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which providers will retire in favor of the next revision, ICD-10-CM, in October 2013.
SNOMED CT codes more numerous -- also more descriptive
Hogan led a medical vocabulary team at UPMC to field questions from Konicek, who is the director of consulting and mapping services for the College of American Pathologists’ SNOMED Terminology Solutions. She’s charged with mapping SNOMED CT terms to ICD codes. The questions typically involved UPMC documentation and coding practices, and anticipated future changes as doctors and nurses gained access to SNOMED CT diagnostic classifications -- to be formatted in standardized problem lists that doctors and nurses can use to call up a patient record.
Using standardized problem lists, too, is a requirement for meaningful use. Eventually, health IT leaders hope that standardizing vocabulary will be one of the forces that help promote interoperability between health care facilities, as well as software and hardware applications.
Fixing the coding for the male patients smoking while pregnant was one of the many problems Hogan and Konicek addressed during the mapping process. They shared their experiences in a presentation on SNOMED CT implementation at the HIMSS10 annual conference earlier this month.
“[UPMC] is a very diverse enterprise. It’s also very geographically scattered -- and unfortunately, so is all our data,” said Hogan, who recently took a teaching position at University of Arkansas for Medical Sciences after two-and-one-half years working as director of UPMC’s terminology services, representing the medical center’s 15 hospitals and 450-plus ambulatory care, cancer and long-term care facilities. “Even when we do have information systems that cover multiple sites, they tend to be separate from other information systems, Hogan said.”
The technical issue that UPMC had to solve -- and with which the health care industry will have to deal in the upcoming four years -- is one of sheer numbers. ICD-9-CM contains about 13,000 diagnosis codes, while ICD-10-CM has more than 68,000. SNOMED CT? About a million code-like concepts and descriptions.
For EHR success, SNOMED CT is a better mousetrap for physicians than the ICD coding databases, which were designed for billing and reimbursement systems, not clinical work, private- and public-sector advocates say. In addition, having SNOMED CT’s larger terminology set can increase quality of care, they say, because it allows more accurate descriptions of a patient’s medical issues in words physicians understand, and doesn’t cross into the administrative interpretations of diagnosis codes that are more familiar to coding staff.
Another way using SNOMED CT and standardized problem lists can help improve care is with research. Right now, a single ICD code sometimes can represent multiple problems or can be a generic description of a medical issue; that makes it hard for researchers to draw conclusions from data without spending time analyzing individual patient records. Sorting by the more specific SNOMED CT codes can give researchers more detailed data, indexed across all of a hospital’s specialties.
Mapping SNOMED CT to EHR systems still a concern
Some clinical leaders endorse the value of SNOMED CT, but making the transition to it from the current ICD-9-CM is a big implementation job. Most physicians don’t have problem lists, period, let alone standardized problem lists, in their EHR systems -- if they’ve even made the leap from paper to electronic health records to begin with. On top of that, there’s the planned industry migration to ICD-10-CM scheduled to take place in the middle of the transition to SNOMED CT.
Dr. William Hogandirector, University of Pittsburgh Medical Center terminology services
Another dimension of the problem involves EHR vendors using their own proprietary descriptions -- and abbreviations -- for patient conditions. Add to that the doctors and nurses muddying the water by adding their own descriptions in an EHR system’s free-text fields.
So how are they going to get the lists mapped to ICD-10-CM via SNOMED CT terminology? Watch the National Library of Medicine and the American Health Information Management Association, which are working on mapping projects. Also, some benevolent private health care systems may step up to the plate and share their maps, too.
However, it’s all still under construction -- and discussion -- at this point, so there’s no clear answer for the solo physician or even the small hospital that might not be able to afford or want to implement one of many bigger, brand-name EHR systems.
“I think the vendors are going to become increasingly sophisticated,” Hogan said, referring to large EHR vendors who, he predicts, will make it a priority to standardize problem lists and hook them into SNOMED CT and ICD terminology for their customers. For the solo doctors and small clinics, “[Health information exchanges] are going need terminology teams, so I think the best bet for the solo doc will be the HIE,” he said.
Let us know what you think about the story; email Don Fluckinger, Features Writer.