Why SNOMED isn’t enough for complete clinical documentation

Don't settle for "good enough" clinical documentation. Learn why robust clinical terminology is key for accurate and seamless clinical data capture.
Female doctor on computer thinking

In this day and age, when electronic medical record (EMR) applications are a required and necessary aspect of healthcare, it is important that the IT and informatics communities continue to provide solutions that assist rather than hinder the delivery of care.

IMO provides a robust clinical interface terminology (CIT) designed for capturing clinical information that is specific and detailed enough to reflect the clinician’s intent. Because we speak the language of the clinician – delivering terms that are clinical, not administrative, and seamlessly integrating them into most EHR platforms – we have been able to alleviate at least some of the burden that requires doctors to act as data entry professionals.

Unfortunately, the capturing of clinical data is only part of the equation. There are many external code sets that are necessary to fulfill various functions. They may be administrative, financial, support other functions such as decision support, or could be related to reporting data or research, to name a few. These codes must also be captured accurately and completely – another burden clinicians struggle with as they are often not coding experts.

Without using an interface terminology such as IMO, healthcare institutions have had to rely on leveraging these code sets directly for documentation and/or utilizing crosswalks to link to other code sets as needed. The following explores some of the shortcomings of this approach.

Clinicians, not coders

The Systemized Nomenclature of Medicine – Clinical Terms or SNOMED CT® is one of the major code sets required for coding, collating, and reporting clinical data. Through its extensive corpus of terms, it has evolved into an ontology that is the standard for these purposes. However, it was not designed for clinical documentation at the point of care. For example, a term such as Stage 2 breast cancer would not return a result in a SNOMED CT browser. This term requires two separate searches. One for breast cancer and an additional search for stage 2. These must then be linked. 

This functionality is by design and has served SNOMED CT well when used for its intended purpose. This approach, however, may not be welcomed by a clinician documenting in a patient chart. Clinicians prefer a single pre-coordinated term and are unlikely to do multiple searches for secondary codes that are very often required. In the above example clinicians are forced to think like SNOMED CT rather than search clinically as they were taught. And they can quickly become frustrated when they are unable to find the exact term for which they are searching.  Additionally, doctors and nurses are not coding experts, specifically SNOMED CT experts. SNOMED CT is a complex ontology that requires specialized training and knowledge to navigate correctly. IMO’s code maps are applied by certified coders which provides much more accurate coding when compared to relying on clinicians who may only have a vague idea of the rules surrounding code selection.

The importance of specificity in clinical documentation 

Another major disadvantage of using a standard code set for documentation is the eventuality that the data captured will be less specific and less accurate. As we become more sophisticated in our electronic documentation, specificity of diagnosis capture will be the required objective, rather than merely code capture. The goal of clinical documentation should be the accurate capture and preservation of the patient condition – and code capture should be an extension of that. The goal should not be to meet the minimum requirements of a reporting agency, but rather to allow our clinical teams to accurately capture clinical situations to positively affect the care of the patient.

While eliminating hyper-specific choices for diagnoses may be a faster path to “checking a box” it can hinder patient care with the loss of important information. As medical treatments become more specialized around genomics and precision cancer treatments, these hyper-specific terms will be required to properly identify these patients.

The goal should not be to meet the minimum requirements of a reporting agency, but rather to allow our clinical teams to accurately capture clinical situations to positively affect the care of the patient.

The best of both worlds

If we do not continue to capture and preserve clinical data with maximum detail, many tangential processes will be negatively impacted. When diagnoses that are more specific are eliminated for the sake of code capture, downstream processes are affected and decision support and other rules are more prone to misfiring as false positives become more common compared to when specific diagnoses are used. 

IMO’s CIT allows for the best of both worlds. Clinical conditions can be captured at a level of detail that is often not contained in standard code sets. Furthermore, these terms are linked to  standard and administrative codes by our coding experts. This assures that all adjacent functions continue seamlessly. Because these codes are applied context free, without the use of crosswalks, we provide the best maps possible. Crosswalks, on the other hand, are error-prone when linking data sets that are quite different, such as SNOMED-CT and ICD-10-CM. In these cases, data is often lost, or worse, errors can be introduced.

While IMO recognizes the absolute need for administrative and standard code sets such as SNOMED CT and ICD-10-CM, we believe that the most, accurate, specific, and user-friendly method to capture these data elements and link these code sets is through the use of IMO’s terminology. This becomes vitally important as we venture into the world of Machine Learning (ML) and Artificial Intelligence (AI) since these new systems will only function as well as the data they are fed. Hopefully these new technologies will advance healthcare by improving patient care on both an individual and population level and relieving some of the burden on our healthcare teams.

To learn how IMO can help your organization streamline clinical documentation for better compliance and patient care, click here in the UK and here in the US – or reach out for a demo.

SNOMED and SNOMED CT® are registered trademarks of SNOMED International.
CPT is a registered trademark of the American Medical Association. All rights reserved.

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