The organization is a treatment facility that provides psychiatric residential and outpatient care as well as primary medical care. Common services provided include psychiatric initial assessments and medication management, group and individual therapy, medical history and physical exams, primary care, and lab work. Nurses staff the residential campuses where medications are stored and administered to patients. There is no pharmacy service, so medications are ordered from a local pharmacy.

A hybrid record system is currently in place. An old electronic medical record (EMR) system with limited functionality is used to record and store most clinical documents, generate discharge summaries, compile treatment plans, and generate reports for billing. Paper charts and documents are used for every other task including provider orders, medication prescribing, medication administration records, consultation requests, lab test reporting, and outcomes data collection.

The current EMR uses standard terminology from the Diagnostic and Statistical Manual IV (DSM-IV) and the International Classification of Diseases 9 (ICD-9). Providers chose standard DSM-IV or ICD-9 diagnoses from a drop-down list when they complete electronic documents. A human coder uses ICD-9 and Current Procedural Terminology (CPT) codes to generate diagnosis and procedure codes for billing. All other information contained in the EMR is input using free-text boxes and is not standardized or coded in any way.

The organization recognizes the limitations and inefficiencies of the current system. Without standard terminologies and codes, there are many inconsistencies and errors. For example, providers manually enter lab tests results and current medications into an electronic progress note using free text. Abbreviations or shorthand are used or information is left out in order to save time typing. This results in misunderstandings because of ambiguity or missing data. Because there is no standard way to write medication orders or prescriptions, errors are committed in the medication administration record and in pharmacy communication. This sometimes results in errors of wrong medication, wrong dose, or wrong timing to the patients. Patient safety is adversely affected, and providers spend extra time correcting errors. Medication reconciliation is a problem without standard names and syntax. Discharge summaries are prepared by individual providers using their own terminology for medication instructions which can be confusing for patients and for subsequent providers.

A new comprehensive and integrated electronic health record (EHR) system will be implemented over the next 18 months. It is recommended that the following health information technology standard terminologies be adopted.

The Health Insurance Portability and Accountability Act (HIPAA) mandates all covered health entities to adopt the International Classification of Diseases 10 (ICD-10) as of October 1, 2014 (www.CMS.gov). Our organization should adopt this standard. The World Health Organization develops, maintains, and updates ICD terms and codes which classify diseases, disorders, abnormal findings, problems, social circumstances, complaints, and causes of injury (www.WHO.int). The ICD-10 version was published in 1990. It can be used in the EHR to select standard terminology for diagnoses and problem lists. It will meet our organization’s needs because it is applicable in mental health and in primary care settings. Problem lists using standard terms help providers develop treatment plans and interventions. The terms and codes can be used for transmission to outside agencies in clinical documents such as consultation requests and discharge summaries. Using ICD-10 terms and codes, these documents can be transmitted electronically with semantic integrity to outside agencies which is a goal of Meaningful Use under the Heath Information Technology Act (HITECH). The use of standard terms and coding will help to eliminate ambiguity and misunderstandings among the various providers both within and outside of our organization. Benefits will include improved efficiency and patient safety.

The DSM-5, which was released this year, can also be used as a standard for diagnostic terminology. The DSM-5 made some changes to the classification of psychiatric diagnoses, eliminated some diagnoses, and added new diagnoses. Therefore ICD-10, which was published much earlier, may lack codes for some of the new psychiatric diagnoses. The DSM-5 uses duplicate ICD-10 codes for some

cases where a unique ICD-10 code does not exist. This could present a challenge if we decide to adopt DSM-5 and ICD-10.

Adopting ICD-10 may also be challenging for providers and for coders. The ICD-10 adds degrees of complexity and specificity to terms in comparison with ICD-9. Providers must get used to describing problems and diagnoses in greater detail, and coders must get used to selecting more complex codes. A three to five number code was used in ICD-9, but more complex alphanumeric codes are used in ICD-10. This creates problems for older EHR systems because fields in databases have to be changed to accommodate the new coding system. Our organization must ensure that the new EHR we purchase can accommodate ICD-10 codes.

Procedure codes are also included in ICD-10 with the Procedure Coding System (www.CMS.gov). However, these codes are mandated only for inpatient facilities. Because our organization is considered an outpatient facility, we should continue to use CPT for procedure codes. The American Medical Association publishes and maintains CPT (www.ama-assn.org). It is used to code office visits of varying complexity and the basic medical procedures that our organization performs. The benefit of using this coding system is to facilitate billing for services. Third party payers use these codes to determine reimbursement rates to the organization. The challenge for our organization is to continue to use the most current version of CPT codes and to train providers to document the requirements for the various codes in order to maximize reimbursement rates.

The organization’s new EHR will include order entry, electronic prescribing, medication administration, and lab test result reporting. It will need the following standards for operation.

The U.S. National Library of Medicine publishes and maintains RxNorm (www.nlm.nih.gov). This system provides standardized names and codes for medications including dose strength and form. These standardized terms and codes can be used for electronic prescribing, computerized provider order entry, and electronic medication administration records. Our organization should adopt RxNorm to help eliminate errors of human transcription and misunderstanding of handwritten orders. The challenge is training providers to use computerized systems where their current workflow does not include electronic systems. Computerized workflows can initially slow down provider productivity and lead to previously unknown errors such as entering orders in the wrong electronic patient record or proximity errors (incorrectly choosing an option from a dropdown list that is near the desired option). Electronic systems usually include alert systems. This can be a benefit such as alerting a provider when he/she tries to prescribe a medication to a patient with a known allergy. It can also be a challenge such as when alert triggers are set to a high sensitivity and cause providers to ignore them (alert fatigue).

The Regenstreif Institute publishes and maintains the Logical Observation Identifiers Names and Codes (LOINC) which is a system for identifying and coding laboratory tests and results and other clinical observations (www.loinc.org). This standard should be adopted so that our providers can order lab tests via the new EHR and so that the EHR can receive lab test results electronically from outside lab systems. Adopting this standard provides syntactic and semantic standards which will ensure that orders are correct and that lab results can be included directly into the electronic patient record without introducing the potential error of human transcription. Abbreviations and individual provider shorthand will be eliminated thereby reducing errors caused by previously ambiguous notations. A challenge to adopting such a comprehensive system will be to keep user interfaces as simple as possible so that providers are not overwhelmed with choices and so that they can quickly and easily identify the lab test they want in order entry systems.

The standard terminologies and coding systems mentioned above are either government mandated (ICD-10) or the most commonly used standards for nomenclature and coding used in the U.S. (DSM, CPT, RxNorm, LOINC). These standards have been adopted by healthcare organizations, insurance companies and third party payers, pharmacy systems (Allscripts, Surescripts), and laboratory systems (LabCorp, Quest Diagnostics).

References:

ICD-10. (2013, September, 9). retrieved October 18, 2013, CMS Web Site: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/

International Classification of Diseases (ICD). (2013). retrieved October 18, 2013, from World Health Organization Web Site: http://www.who.int/classifications/icd/en/

2013 ICD-10 PCS and GEMs. (2012, November, 26). retrieved October 18, 2013, CMS Web Site: http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html

CPT - Current Procedural Terminology. (2013). retrieved October 18, 2013, American Medical Association Web Site: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page

RxNorm. (2011, December, 5). retrieved October 18, 2013, from U.S. National Library of Medicine Web Site: http://www.nlm.nih.gov/research/umls/rxnorm/

Logical Observation Identifiers Names and Codes. (2013). retrieved October 18, 2013, from LOINC Web Site: http://loinc.org/