Welcome to the final installment of our four-part blog series dedicated to the importance of data mapping. If you are just now tuning in, be sure to check out the last three blogs discussing the importance of lab, medication, and allergy mapping.
The topic of this fourth and final blog post is the importance of mapping problem lists and diagnoses across your electronic health records (EHR) system and other health IT systems, specifically the following:
- The clinical and financial benefits of accurately mapping problems and diagnoses
- Essential elements of a successful mapping strategy
- How Health Language solutions can help overcome these challenges
- Real client uses cases and successful outcomes
Why is mapping patient problem lists and diagnoses important?
Accurate documentation of a patient’s problem list is critical for improving clinical outcomes and optimizing reimbursement in today’s healthcare environment. Accurately capturing this information at the point of care is especially crucial as this information has the power to impact the safety of patients and multiple downstream healthcare operations, from financial planning and billing to care coordination and population health initiatives.
When compiled accurately and thoroughly, problem lists have the potential to immediately align multi-disciplinary treatment efforts as patients are triaged from unit to unit or provider to provider. Because of this, problem lists have been a primary focus area for establishing regulatory requirements around improving electronic exchange of critical patient data.
Clinical and financial leaders must prioritize proper documentation to ensure accuracy of patient problem lists, to avoid negative downstream impacts related to analytics, clinical decision support, and healthcare compliance and reimbursement. Incomplete and inaccurate documentation puts healthcare organizations at risk of experiencing:
- Inaccurate diagnoses due to lack of specificity
- Incomplete data related to patient conditions for analytics initiatives
- Ineffective patient safety alerts
- Decrease in productivity with increased number of coder queries
- Inability to accurately report quality measures
The benefit of mapping SNOMED to ICD-10
To establish a single source of terminology truth and promote semantic interoperability, diagnoses and problems must be mapped to an industry standard. Standardizing the way health IT systems read and recognize conditions enables consistency of documentation within electronic health records and increases the likelihood of accurate code capture and data sharing.
As the industry health IT standard for coding problems and diagnoses, SNOMED CT® (Systematized Nomenclature of Medicine Clinical Terms), is the world’s most comprehensive multilingual clinical terminology, encompassing more than 300,000 codes, terms, synonyms, and definitions for human and non-human concepts. As with its well-known coding counterpart, ICD-10, a key benefit of SNOMED CT is the granularity of its concepts, allowing for greater specificity in the documentation of patient issues.
When mapped to other international standards such as ICD-10, SNOMED CT can promote revenue cycle efficiency and accuracy, eliminating the need for identifying the correct code from ICD-10’s expansive library of more than 90,000 codes.