Letting clinicians “speak clinician”

As IMO expands into the insights space – helping providers to extract greater value from EHR data – the importance of our robust clinical interface terminology solutions has come into even sharper focus. Since terminology is the foundation of all that we do, we asked Vidhya Sivakumaran, our Director of Content Delivery, to take us back to the basics and explain how we build medical coding software – and why the process is integral to your EHR experience.

At IMO, we strive to create terminology solutions that allow those in a clinical setting to better focus their attention on caring for patients. In order to achieve this important objective, the IMO team adheres to a set of guiding principles that make up the cornerstone of our terminology offerings, such as always keeping the clinician in mind and facilitating knowledge exchange.

Because one word choice doesn’t fit all

To start, IMO focuses on ensuring clinicians can speak like clinicians. Our goal is to eliminate the need for them to document patient problems using terms that aren’t clinically appropriate and to then leverage this natural syntax and phrasing as it relates to administrative coding systems, like ICD-10-CM and CPT terms. We do this by creating a clinically-relevant terminology that is then linked to the appropriate medical terminology standard. This means that those using our products only need to perform a search representative of the clinical meaning of the desired diagnosis or procedure. 

Our terminology solutions also provide individuals with the opportunity to speak their preferred version of clinician. Those using IMO terminology products have access to a variety of lexicals – or terms that describe a diagnosis or procedure associated with certain codes – constructed to match the numerous ways that individual clinicians may be inclined to speak in different medical contexts. In order to support this functionality, our offerings provide word variance in search. This means that in instances where there is more than one way to say something, such as “heart attack” versus “myocardial infarction,” we support that in our content, thereby helping clients more easily locate what they need and want to say.

In other words, our terminology enables clinicians to focus on “speaking clinician” because we handle speaking the language of the administrative coding vocabularies.

Building a shared terminology

In addition to supporting word variance, our terminology solutions support associations between acronyms and words that are common in clinical practice, such as “MI” for myocardial infarction, but can be tricky to map because of their multiple potential meanings. This ultimately enhances the end user experience and makes our terminology more accessible. If there is something missing or difficult to locate in our content, we have a system that allows customers to pass this information along to us. IMO works to streamline and simplify the user experience by evaluating these requests and incorporating additions and modifications to our content where clinically appropriate. As with word variance, we strive to support all the different ways our clients may speak by linking a variety of phrases that are clinically equivalent with the appropriate billing codes.

However, unique to IMO’s terminology solutions is that we provide clients with all of our lexicals, regardless of whether or not they have used them before. When we receive terms from one client, we align them with our standardized internal dictionary of terms, and then that client gets back their file. But, it doesn’t stop there. Clients also receive the benefit of all our other content within that solution, regardless of whether it aligns with terms used in their files or not. Naturally, all of that content will have been vetted, standardized, and coded to the appropriate external vocabularies. This is how we build a shared terminology, and support all our users with the ability to document using the appropriate context and meaning for their specific patient.

Following these principles and creating a flexible solution allows us to provide our clients with the ease, flexibility, nuance, and ability to document, and ultimately bill, as required.

To learn more about IMO’s terminology solutions, click here.

CPT is a registered trademark of the American Medical Association. All rights reserved.

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