A clinical decision support system designed specifically for ICD-10 awareness can improve coding data capture, according to Allan Strongwater, MD, senior vice president of medical informatics at medCPU.
Dr. Strongwater recently wrote about the benefits of a CDS system designed for ICD-10 awareness — and how it can help by delivering ICD-10-specific clinical documentation improvement — in an article published by ADVANCE.
Here are three thoughts from Dr. Strongwater.
1. Align best practices. Dr. Strongwater said CDS, which is designed to align clinical decision-making with evidence-based best practices, can align clinical documentation with ICD-10 best practices by reading EMR entries as they are being recorded and notifying clinicians of opportunities to use more particular ICD codes. "The result, greater documentation precision — which was the entire point of the transition to ICD-10 — without requiring clinicians to master and memorize the greatly expanded code set," he wrote.
3. Assist accurately. For the CDS system to accurately assist with clinical documentation improvement, it has to include a complete clinical picture of the patient for whom care is being documented, according to Dr. Strongwater. "This requires the ability to read and interpret all details in the patient's EMR — unstructured free-text notes as well as structured documentation — and to gather information from external information systems, such as those in labs and imaging departments," he wrote.
3. Read clinical documentation. Dr. Strongwater said the CDS system must also be able to read clinical documentation as it is being recorded. He noted that a CDS system with these capabilities can issue a pop-up suggestion within the EMR screen when conditions indicate the need to document at a higher level of detail or reimbursable code.