ICD-10: are you ready for a brave new world?

The ICD-10 transition will be an evolutionary process. Relying on the EHR or certified coding staff alone will not be sufficient. The EHR can facilitate easy search tools that assist the provider in selecting a diagnosis. Billing staff are an invaluable resource to help validate that coding and documentation are in sync but the burden will clearly rest on the provider. The provider will be juggling a new code structure, drilling down to new levels of complexity and ensuring their documentation supports the specificity of the new codes selected, all while managing a full patient schedule. Education for the provider will be of paramount importance as they navigate this brave new world.

Termos identificados em uma clínica médica e classificados como não constantes na CIPE / Termsidentified in a medical clinicandclassified as unlisted in the ICNP / Términos identificados en una clínica médica y clasificados como faltantes enla CIPE

O objetivo deste estudo foi identificar termos não constantes na taxonomia CIPE® Versão 2.0 e na nomenclatura de uma clínica médica. A coleta de dados ocorreu no período de fevereiro a outubro de 2010, em que foram agrupados termos que configuravam sinais e sintomas do cliente, embasando a construção de afirmativas diagnósticas, resultados e intervenções de enfermagem. Inicialmente, contava-se com 25 termos não constantes; após processo de normalização e atualização de acordo com a CIPE® Versão 2.0, restaram três termos, que foram distribuídos de acordo com o modelo dos sete eixos, sendo conceituados com base na literatura vigente e em discussões estabelecidas pelos integrantes de um subprojeto de extensão. Sabendo-se da importância da linguagem padronizada para estabelecer uma comunicação unificada entre os profissionais de Enfermagem, é que se propõe este estudo, sendo de grande relevância à inserção de termos que configuram a prática desta clínica.

The objective of this study was to identify terms that are not listed in ICNP 2.0 taxonomy and in the nomenclature of a medical clinic. Data collection was performed in the period from February to October of 2010, forming groups of terms that represented the clients? signs and symptoms and providing the foundation for the construction of nursing diagnoses, outcomes, and interventions. In the beginning, 25 unlisted terms were identified. After the normalization and updating process recommended by the ICNP 2.0, only three terms remained, which were distributed according to the seven axis model and conceptualized based on the current literature and in discussions with members of a related extension studies project. It is known that standardized language is important in establishing homogeneous communication among nursing professionals, hence the present study is proposed, which is of great relevance for the inclusion of terms that represent the practice of this clinic.

Se objetivó identificar términos faltantes en la taxonomía CIPE® Versión 2.0 usados en la nomenclatura de una clínica médica. Datos recolectados entre febrero y octubre de 2010, período en el que se agruparon términos que configuraban signos y síntomas del paciente, dando base a la construcción de afirmaciones diagnósticas, resultados e intervenciones de enfermería. Inicialmente, se contaron 25 términos faltantes; luego del proceso de normalización y actualización acorde con la CIPE® Versión 2.0, quedaron 3 términos que fueron distribuidos de acuerdo con el modelo de los siete ejes, conceptuándoselos en base a la literatura vigente y en discusiones establecidas por los integrantes de un sub-proyecto de extensión. Conociéndose la importancia del lenguaje estandarizado para establecer una comunicación unificada entre los profesionales de Enfermería, es que se propone este estudio, considerándose de alta relevancia la inclusión de términos que configuran la práctica de esta clínica.

Mapping medical records of gastrectomy patients to SNOMED CT.

The purpose of this study is to explore the ability of SNOMED CT to represent narrative statements of medical records. Narrative medical records of 281 hospitalization days of 36 patients with Gastrectomy were decomposed into single-meaning statements, and these single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problems and treatments were mapped to SNOMED CT concepts. A total 4717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and treatments, about 85.5% statements were fully mapped to SNOMED CT. The rest of the statements were partially mapped. This mapping result implies that physicians' narrative medical records can be structured and used for an electronic medical record system.

SNOMED CT implementation: implications of choosing clinical findings or observable entities.

Internationally, it is a priority to develop and implement semantically interoperable health information systems.[1] One required technology is the use of standardised clinical terminologies. The terminology, SNOMED CT, has shown superior coverage compared to other terminologies in multiple clinical fields. The aim of this paper is to analyse SNOMED CT implementation in an Electronic Health Record (EHR). More specifically, differences and consequences of applying clinical findings (CFs) as an alternative to observable entities (OEs) is analysed. Results show that CFs represents the content of the templates with better coverage, with more parent concepts and with a higher degree of fully defined terms than the OEs. We discuss the possibility to further evaluate the observable entity hierarchy to overcome a potential overlapping use of the two hierarchies.

A classification of hospital-acquired diagnoses for use with routine hospital data.

OBJECTIVE: To develop a tool to allow Australian hospitals to monitor the range of hospital-acquired diagnoses coded in routine data in support of quality improvement efforts. DESIGN AND SETTING: Secondary analysis of abstracted inpatient records for all episodes in acute care hospitals in Victoria for the financial year 2005-06 (n=2.032 million) to develop a classification system for hospital-acquired diagnoses; each record contains up to 40 diagnosis fields coded with the ICD-10-AM (International Classification of Diseases, 10th revision, Australian modification). MAIN OUTCOME MEASURE: The Classification of Hospital Acquired Diagnoses (CHADx) was developed by: analysing codes with a "complications" flag to identify high-volume code groups; assessing their salience through an iterative review by health information managers, patient safety researchers and clinicians; and developing principles to reduce double counting arising from coding standards. RESULTS: The dataset included 126,940 inpatient episodes with any hospital-acquired diagnosis (complication rate, 6.25%). Records had a mean of three flagged diagnoses; including unflagged obstetric and neonatal codes, 514,371 diagnoses were available for analysis. Of these, 2.9% (14,898) were removed as comorbidities rather than complications, and another 118,640 were removed as redundant codes, leaving 380,833 diagnoses for grouping into CHADx classes. We used 4345 unique codes to characterise hospital-acquired conditions; in the final CHADx these were grouped into 144 detailed subclasses and 17 "roll-up" groups. CONCLUSIONS: Monitoring quality improvement requires timely hospital-onset data, regardless of causation or "preventability" of each complication. The CHADx uses routinely abstracted hospital diagnosis and condition-onset information about in-hospital complications. Use of this classification will allow hospitals to track monthly performance for any of the CHADx indicators, or to evaluate specific quality improvement projects.

Cáncer gástrico por laparoscopia: análisis de los datos del Registro Nacional de Cirugía Gástrica por Laparoscopia / Gastric cancer and laparoscopy: analysis of data from the national register of laparoscopic gastric surgery

Objetivo: Describir los datos enviados al Registro Nacional de Cirugía Gástrica por laparoscopia y analizar el tipo de cirugía, la reconversión, las complicaciones postoperatorias y la mortalidad. Pacientes y método: Desde marzo de 2005 a julio de 2008 han sido remitidos al registro 302 pacientes a través de un cuestionario ubicado en la página web de la Asociación Española de Cirujanos, donde se registraron datos clinicopatológicos, características de la cirugía realizada, reconversión y morbimortalidad. Resultados: Se ha intervenido a 245 pacientes por adenocarcinoma gástrico, 35 por tumores estromales y 22 por otras afecciones. En los adenocarcinomas gástricos se realizó cirugía resectiva en 232 (95%) casos. La localización predominante fue el tercio distal y el tipo de tumor más frecuente, el intestinal. El 34% fueron tumores localmente avanzados. Se realizó una linfadenectomía D2 en 117 casos, D1 en 105 y D0 en 6. Se realizó reconversión en 21 (9%), y entre las causas destacan las dificultades técnicas. Se han descrito complicaciones postoperatorias en 72 (31%) casos, entre las que destacan por su gravedad las fístulas digestivas. Hubo una mortalidad postoperatoria del 6%, y las causas más frecuentes fueron la sepsis por fuga anastomótica y las complicaciones cardiorrespiratorias. La estancia media hospitalaria en los pacientes que no presentaron complicaciones fue de 9,2±3 días. Conclusiones: La gastrectomía laparoscópica en el cáncer gástrico es un procedimiento factible que no está exento de dificultades técnicas. Una considerable tasa de complicaciones postoperatorias pueden llegar a condicionar los beneficios de la cirugía mínimamente invasiva(AU)

Objective: To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality. Patients and Method: From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed. Results: A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause . Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2±3 days.Conclusions: Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications(AU)

Burden of concomitant asthma and COPD in a Medicaid population.

BACKGROUND: Asthma and COPD can significantly affect patients and pose a substantial economic burden for both patients and managed-care plans. This study compares utilization outcomes in patients with asthma, COPD, or co-occurring asthma and COPD in a Medicaid population, and assesses the incremental burden of COPD in patients with asthma. METHODS: We queried medical claims of Medicaid patients aged 40 to 64 years with asthma and/or COPD filed between January 1, 2001, and December 31, 2003, from encounter data. COPD patients were identified based on at least one claim with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes 491, 492, 496; and asthma patients were identified on the basis of ICD-9 code 493 as diagnosis. We analyzed annual utilization and cost of hospitalizations, physician, and outpatient services attributable to asthma and/or COPD. RESULTS: The analysis included a total of 3,072 asthma, 3,455 COPD, and 2,604 COPD/asthma patients. COPD/asthma co-occurring disease has higher utilization of any service type than either disease alone. Compared with asthma patients, COPD patients were 16% and 51% more likely to use physician (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.01 to 1.34) and inpatient services (OR, 1.51; 95% CI, 1.31 to 1.74), respectively; and 60% less likely to use outpatient services (OR, 0.40; 95% CI, 0.35 to 0.46). Compared with asthma patients, COPD patients and COPD/asthma co-occurring patients cost 50% (OR, 1.50; 95% CI, 1.3 to 1.74) and five times (OR, 5.25; 95% CI, 4.59 to 6.02) more for total medical services, respectively. CONCLUSION: Our data suggest that patients with COPD and co-occurring COPD/asthma were sicker and used more medical services than asthma patients. The incremental burden of COPD to patients with asthma is significant.

[The German diagnosis-related groups in urology: reproducibility and quality of coding]. / G-DRG-System für die Urologie : Reproduzierbarkeit und Kodierqualität.

BACKGROUND: The German diagnosis-related group (G-DRG) system is based on the belief that there is only one specific coding for each case. The aim of this study was to compare coding results of identical cases coded by different coding specialists. MATERIAL AND METHODS: Charts of six anonymous cases -- except final letter and coding -- were sent to 20 German departments of urology. They were asked to let their coding specialists do a DRG coding of these cases. The response rate was 90%. RESULTS: Each case was coded in a different way by each coding specialist. The DRG refunding varied by 6-23%. The coding differences were caused by different interpretations of definitions in the DRG system and also by inaccurate chart analysis. CONCLUSION: The present DRG system allows a wide range of interpretation, leading to aggravation of the ongoing disputes between hospitals and insurance companies.

Practical issues in using SNOMED CT as a reference terminology.

SNOMED CT was created by the merger of SNOMED RT (Reference Terminology) and Read Codes Version 3 (also known as Clinical Terms Version 3). SNOMED CT is considered to be among the most extensive and comprehensive biomedical vocabularies available today. It is considered for use as the Reference Terminology of various institutions. We review the adequacy of SNOMED CT as a Reference Terminology and discuss the issues in its use as such. We discuss issues with content coverage of various clinical domains, data integrity and validity, and the update frequency of SNOMED CT, and why SNOMED CT alone is not adequate to serve as the Reference Terminology of a healthcare organization.

[International curriculum for medical coders. Recommendations of the Education Committee of the WHO Family of International Classifications Network]. / Internationale Ausbildungsinhalte zum medizinischen Kodierer der ICD. Richtlinien des Education Committee des Netzwerkes der WHO-Klassifikationszentren.

Nationally collected data for mortality and morbidity are coded according to the International Classification of Diseases (ICD). From the coded data international statistics are compiled. Due to national variations in coding, data are not always comparable. With the development of core curricula for mortality and morbidity coding, the Education Committee of the WHO Family of International Classifications Network developed an entry level standard for the education of medical coders. Through this enhanced and internationally consistent level of education the quality of the collected data can be increased.

Classifications used by Australian forensic odontologists in identification reports.

Forensic odontologists are repeatedly called upon to assist in the identification of deceased persons. A great deal of information is available in the literature as to how and why comparative dental investigation of identification is performed but there is little information on the descriptive terms used in reporting these identifications. A forensic odontology report sets out the findings of a comparison between antemortem and postmortem evidence and indicates the odontologist's opinion on the identification. This opinion needs to be defendable in a court of law. This paper investigates the classifications utilised in the six states and two territories of Australia and reflects on the differences. Three states of Australia use American Board of Forensic Odontology classifications, whilst the remaining regions use a modified format. Since there are no significant legal, cultural or religious differences, and similar practitioners and clients, variation between regions within Australia would seem hard to justify. National standard terminology should be encouraged.

Using SNOMED CT codes for coding information in electronic health records for stroke patients.

For a project on development of an Electronic Health Record (EHR) for stroke patients, medical information was organised in care information models (templates). All (medical) concepts in these templates need a unique code to make electronic information exchange between different EHR systems possible. When no unique code could be found in an existing coding system, a code was made up. In the study presented in this article we describe our search for unique codes in SNOMED CT to replace the self made codes. This to enhance interoperability by using standardized codes. We wanted to know for how many of the (self made) codes we could find a SNOMED CT code. Next to that we were interested in a possible difference between templates with individual concepts and concepts being part of (scientific) scales. Results of this study were that we could find a SNOMED CT code for 58% of the concepts. When we look at the concepts with a self made code, 54.9% of these codes could be replaced with a SNOMED CT code. A difference could be detected between templates with individual concepts and templates that represent a scientific scale or measurement instrument. For 68% of the individual concepts a SNOMED CT could be found. However, for the scientific scales only 26% of the concepts could get a SNOMED CT code. Although the percentage of SNOMED CT codes found is lower than expected, we still think SNOMED CT could be a useful coding system for the concepts necessary for the continuity of care for stroke patients, and the inclusion in Electronic Health Records. Partly this is due to the fact that SNOMED CT has the option to request unique codes for new concepts, and is currently working on scale representation.