Where the Rubber Meets the Road in MD Documentation: An Emergency Physician Perspective

Code status discussion, smoking cessation discussion, procedure notes, critical care notes. It could really be any form of documentation that can be used repeatedly. And those provide a starting point for users, where they can go in and customize those for themselves. The beauty of it is that when you take tools like those, and apply natural language processing to them, we’re then able to dredge data out of otherwise-unstructured text. For example, Cerner and Nuance have taken Nuance’s natural language processing solution and have put it into a tool that will provide real-time feedback to physicians on the quality and appropriateness of their documentation, related to necessary ICD-10 elements. As you know, there’s a necessary increase in specificity and acuity documentation related to ICD-10. That’s going to be a major challenge for us both in the ED, and everywhere in medicine. But when we have tools like NLP embedded into the EMR, as is the case now with Cerner, that’s an advance.

What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, at this moment in time?

October 2014 is the deadline for compliance with ICD-10 documentation, and it’s coming at us like a freight train. And the interesting thing is, in order to deploy these technologies to achieve those standards, providers must be documenting electronically. So with that said, we need to be focusing now on getting the docs into the record and documenting electronically; so now, in the next six months, is the time to focus on getting them into adoption in the EMR and in physician documentation.

Is there anything else you’d like to add?

So that is key right now, getting them in, increasing adoption rates, but also planning to apply these recently developed and developing technologies to assist the providers with regard to the increased scrutiny that will be applied relative to ICD-10, because as physicians, we’re not going to be able to do it alone. We already get constant feedback from coders; and the stakes will be higher when ICD-10 comes, so it’s time to put those tools into place, in order to meet those regulatory elements.