Wednesday, January 9, 2013

Value Cases for Clinical Documentation Improvement

As BIDMC prepares for ICD10, we're examining the entire clinical documentation process and asking how best to leverage the work we must do to support ICD10 with the innovations we believe will transform our workflow.

As mentioned in a previous post, we're working with several innovators to re-examine assumptions we made for decades about clinical documentation.

Here's an analysis of the types of projects we could do, the challenges, and the proposals, stratified into documentation improvement, structured documentation, code capture, validation, billing, and audit/review categories.  

Imagine the following workflow:

An orthopedist sees a patient for a hip fracture and writes a comprehensive note using a fracture specific template to capture a combination of structured and unstructured data.  Upon saving the note, the clinician is reminded to add important details such as co-morbidities, anesthesia risk factors, and patient preferences for treatment to the note, assuming a guideline and computer assisted coding could be used to trigger such reminders.  As the note is signed, the clinician is presented with a short list of SNOMED-CT codes which capture the essence of the clinical information in the note.   The orthopedist checks the codes that apply.    An expert human coder reviews the chart and validates the codes, then a bill can be submitted backed by complete/codified documentation that supports future audit processes.

Our next step is continue to work with vendors to develop scope and budgets for these projects, then determine what we can implement/afford in the short/medium/long term.  

I'll let you know which of these many projects we decide to do on the path to ICD-10 go live.


Dr_SteveA said...

It seems to me that stovepipe docs are much easier to support in generating structured documentation than heterogeneous docs. Any feel for what the percentage is of heterogeneous docs? I'd suspect the trend is declining as the newer physicians may be less drawn to the colorful dictations of the past.

Andy Wiesenthal said...

Enjoying the blog as always. I am hoping that one day you will reference the potential of the CMT (now being released as part of SNOMED-CT by the IHTSDO and the NLM) as a way of translating the modestly arcane expressions of SNOMED-CT into clinician friendly and patient friendly terms, 1:1. Implementing these vocabularies as imbedded features of routine documentation, much as you describe, will take the job of coding largely out of the human realm and into the machine realm, where it belongs.