Electronic Medical Record Upgrade to Improve Patient Care

Washington Hospital's electronic medical record will soon have more detailed information about diagnoses and treatments in the medical records of hospital patients and patients will benefit from the more specific diagnoses provided by the enhanced system, according to Michelle Smith, EPIC Director, Ambulatory Clinical Applications.

The upgraded coding system will allow physicians to understand a patient’s medical issues much more quickly, she explained.

“For example, if a patient has been treated for stomach pains and subsequently has gone to the emergency room because his/her condition has taken a turn for the worse, the ER doctors can quickly obtain prior detailed diagnostic details from the patient’s electronic medical records,” Ms. Smith said.

“This means appropriate treatment can begin much more quickly and the patient’s medical records subsequently will include a detailed report of the ER visit.”

ICD, or the International Classification of Diseases, is the standard international diagnostic tool for health management, clinical management, epidemiology and reimbursement systems. Under the auspices of the World Health Organization, the ICD system is used by 117 countries throughout the world.

Washington Hospital, along with other hospitals and medical providers throughout the United States, is upgrading its ICD system to allow for more detailed coded descriptions of medical diagnoses. The current system, ICD-9, allows for 13,000 codes; the upgraded ICD-10 will increase the number of codes to 63,000. Codes for different medical procedures have been increased from 4,000 to 87,000.

Not only are the number of codes increased but the length of each code has been increased from five digits to seven digits.

“The increase in number of codes and the length of each code will allow a more detailed yet concise diagnosis and treatment description to be included in a patient’s medical records,” added Mark Moran, Executive Director of Information Services. “All of this will result in a more accurate patient story for all healthcare providers leading to improved patient care and a healthier community.”

The ICD-10 upgrade also will provide much better information for:

• Conducting research, epidemiological studies and clinical trials
• Setting health policy
• Measuring quality, safety and efficacy of care
• Tracking public health and risks
• Improving financial reimbursement systems
• Preventing and detecting healthcare fraud and abuse
• Managing the use of resources
• Providing needed information for operational and strategic planning and for designing improvements in healthcare delivery systems

Washington Hospital continually works to upgrade its systems and procedures, Ms. Smith said. The ICD-10 upgrade will keep the hospital on the cutting edge of health care, consistent with the hospital’s primary mission of providing the very best care for its patients and all residents of the district.