Friday, February 6, 2009

Does the Information get Captured - Not even a Fraction of it

In an HIT moment with Andy Kapit, the CEO of Coderyte Mr HISTalk explores the trouble with coding. There are some good insights into the challenges facing the clinicians in the system and several great quotes.
They down-code because they are afraid to get audited, afraid that the system will not be reasonable. They are afraid to stand out and afraid that the fact that their patients are ‘sicker’ means that their higher codes will make them stand out. They are afraid — period.
There is enough in the way of pressures without adding more burden to clinicians in worrying about audit's and the veritable army of folks and companies who are employed just to investigate and find discrepancies. Ironically they are probably using more sophisticated tools to identify poor coding than the doctors themselves are using to create the codes.
As Andy says it creates "adversarial culture not only reduces the morale of the physicians, it forces the data to be more flawed than it needs to be"'s true it does, fear is not the answer. It's just like tax returns as described in a recent article in USA Today that suggested there will likely be an increase in tax cheating because of the high profile cases of folks who appear to have gotten away with it but:
Americans are among the most law-abiding taxpayers in the world, in part because the IRS uses computer matching programs that make it difficult to cheat, says Walter Pagano, a former IRS agent who is a partner at accounting firm Eisner.
But this is not clinicians cheating but a fundamentally flawed system cheating them through fear. As Andy said - talked about flawed....
Think about it — the most complex series of events most people endure in their lifetimes are reduced to three-, four- or five-digit codes
The heritage of these codes dates back to Henry VIII and the tabulation methodology used by Graunt to describe the 50 or so causes death that were the precursor to ICD coding system (this is from memory but the original article was in the Journal of Public Health: Public health, data standards, and vocabulary: crucial infrastructure for reliable public health surveillance. and I cannot find the copy of the article so if you have this please send it to me)

But it was this that really struck a cord
Physicians have these well-trained powers of observation and, with the full color of their narrative, describe what is wrong with us and what they are going to do about it. In that language are rich and complex concepts — some of which are negated, historical, related to a family member, or are equivocal because more information is needed. Does all of that valuable information get captured in the medical coding process? Not even a fraction of it. The information captured in the record accurately reflects the actual health of the patients. The information healthcare uses to evaluate the quality of care and outcomes is inaccurate — out of fear and is both measuring and rewarding the wrong things.
Excellent points indeed. To further complicate the issue the content is then dumped into text based files that contain a one dimensional view of much better to start storing this information in a richer more suitable container to capture the full story.... The Healthstory: "Comprehensive electronic clinical records that tell a patient’s complete health story." Such information to include the rich complex concepts and whatever codes are necessary to make the information computer interpretable. It can also include the billing codes and other richer vocabularies including Snomed-CT, Radlex and even ICD-10 should that ever arrive.

The project needs more members, both those providing the capabilities and the information as well as those consuming or using the information. You can sign up here.

I'd love to hear feedback on the Healthstory project - good and bad. If you are not a member - why not?

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