Why clinical documentation with granularity matters in a pandemic

Back in May, IMO’s Chief Clinical Officer, Steven Rube, MD, FAMIA, sat down with HIMSS to talk about how the COVID-19 pandemic has highlighted key areas in clinical documentation where the process of recording patient information is not intuitive – and why having greater specificity in clinical notes is critical to making the most of the patient record.

Click below to listen to the full interview, or continue reading for excerpts from Dr. Steven Rube’s conversation with HIMSS on the need for granular clinical terminology to enable effective patient data management.

HIMSS: How has COVID-19 impacted the ability to get the complete, accurate picture of the patient?

Steven Rube: From the time the electronic medical record was introduced, there’s always been a [tension between] the ability for the clinician to document accurately at the point of care and also capture the standard administrative codes needed to extract that data.

I think COVID-19 – both in the acute setting and in the chronic setting – just magnified that challenge. We didn’t have the standard and administrative structured data to accurately capture what the clinicians were seeing at the point of care.

Clinicians were having difficulty finding the structured terms with the correct mappings to describe these patients. We had basically two codes: COVID-19 or suspected COVID-19. We know in the real world you need much more richness and clinical granularity in your terminology to describe these. And that’s the specific data we need to extract – for both retrospective and prospective analysis.

HIMSS: Talk about the impact of not being able to get at the patient data – to manage it and exchange it – for the various stakeholders like clinicians, operations, financials, and others.

SR: Any of those areas you wish to effect, either policy or process, it’s all going to be dependent on the quality of the data you’re extracting. If you can’t describe your patients accurately, if everybody who has COVID-19 looks the same, it’s going to be difficult to make those decisions – whether those are clinical, financial, policy, or even research decisions.

We have a lot of terms. We have COVID-19 terms, and we have pneumonia terms. But how can you identify that this is pneumonia due to COVID? That’s the critical point here. People who were COVID-19 positive with no symptoms were very different from those with symptoms. We need to be able to – very quickly – pull from the data what reasons we could identify from that.

HIMSS: How has the pandemic impacted quality improvement initiatives that rely on complete and accurate data?

SR: Now, we realize that it’s not enough to capture a set of high-level codes that were not necessarily designed for this purpose. Even with the richness of ICD-10-CM, that’s not enough. We need to go beyond that, beyond SNOMED CT®.

We need a terminology written in our language as physicians and nurses – the language we were taught to [use to] capture [diagnoses] at a level of specificity we need so that later someone can come and look at this data and say they learned x from this, very easily, without having to go through it with a fine-toothed comb and manually extract the clinical data. And we’re starting to do that, I think.

Learn how IMO Core’s clinical terminology helps clinicians document with improved accuracy and granularity at the point of care in this short video.

SNOMED and SNOMED CT® are registered trademarks of SNOMED International.

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