Physician's Coding Strategist-Coding method links electronic medical records

Process simplifies research, record sharing

As a pathologist, John Neff, MD, FCAP, is constantly asked to provide extensive and wide-ranging information on patients. For instance, a recent request was for all patients diagnosed with carcinoma of the lungs for the past four years. That's when Neff, chairman of the department of pathology at the University of Tennessee in Knoxville, puts SNOMED to use.

SNOMED, or Systematized Nomenclature of Medicine, is a method for coding electronic medical records to enable clinicians or researchers to share the information no matter what kind of medical record system they use. SNOMED can be encoded into whatever electronic medical records software physicians use.

The method was developed by SNOMED International, a not-for-profit arm of the College of American Pathologists. Neff is chairman. "If I didn't have the data coded, it would be an impossible task for me. As it is, I simply enter into my computer 'lung, carcinoma,' and conduct a query," he says. "It's a great way to do research, and in the future it will be a great way to link all the records together," he says.

The average patient today has 11.2 different medical records, and every provider has a different method of recording the information, Neff says. The Health Insurance Portability and Accessibility Act (HIPAA) makes electronic medical records a necessity. "We cannot continue this paper mess that we are dealing with now. We have to be able to get administrative information from one employer to another or one insurer to another or one state to another," Neff says.

However, he points out, electronic data aren't going to be much easier to handle than paper records unless the way the information is recorded is standardized. "Stop and think of any other large and complicated industry in which you come in contact. Whether it's a bank, a car dealer, or a health club, the records are likely to be kept on a computer," he says.

All physicians have a problem with records, Neff asserts. Even after paper records are reduced to an electronic format, you still have to review pages of papers to find one little fact.

SNOMED includes 190,000 synonyms, 121,000 concepts, and the relationship between them. Each is coded. If you are interested in a group of patients with elevated blood pressure, what kind of insulin the majority of your patients are using, the results of all pap smears, or whether there was improvement in activity status after using one kind of anti-inflammatory drug, you can find it with just a few keystrokes, Neff says.

The process works this way: If you use software in which SNOMED is encoded, the software automatically codes the data you enter as you document the patient's chart. "At the user interface, things won't change that much except that the input will have to be structured," he says.

For instance, if Neff wants to research left lung biopsies, he enters the SNOMED code for lung, left, biopsy and calls up a database of all patients who received the biopsy. "Doctors are weighted down the responsibilities for reporting information in their charts to one or another accreditation agencies, insurance companies, federal payers. You never know what someone will ask you. If it isn't coded, someone has to pull all the charts and find that information. SNOMED allows you to do this in any variation."

For more information on SNOMED, visit its Web site at www.snomed.org.