The coming ICD-10 transition is about more than converting ICD-9 codes to ICD-10 codes. In many cases, this means changing workflow.
John Halamka, Chief Information Officer of Beth Israel Deaconess Medical Center, outlines how he wants to change how clinical documentation is captured at the hospital. And it involves more than capturing more detail.
What's interesting is that Halamka outlines a problem with clinical documentation that has nothing to do with medical codes. It's a problem based upon legibility and collaboration. The solution isn't just an electronic health record (EHR). He wants a "daily note" that's created and shared on a Facebook-like app. All the data on a patient is collected and locked into a daily record by a physician. To make this happen, Halamaka breaks down the solution into five pieces:
John Halamka, Chief Information Officer of Beth Israel Deaconess Medical Center, outlines how he wants to change how clinical documentation is captured at the hospital. And it involves more than capturing more detail.
What's interesting is that Halamka outlines a problem with clinical documentation that has nothing to do with medical codes. It's a problem based upon legibility and collaboration. The solution isn't just an electronic health record (EHR). He wants a "daily note" that's created and shared on a Facebook-like app. All the data on a patient is collected and locked into a daily record by a physician. To make this happen, Halamaka breaks down the solution into five pieces:
- "Disease specific templates"
- "Technology to capture free text and populate the templates i.e. my Wikipedia/Facebook concept describe above."
- "Natural language processing to codify SNOMED-CT concepts"
- "Mapping of SNOMED-CT concepts to ICD10 codes"
- "Rules to ensure documentation is complete enough to justify the ICD10 codes"
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