Rather than an Electronic Medical Record (EMR), which simply digitizes a patient chart, Electronic Health Records (EHRs) provide methods for capturing actionable, codified data related to patient encounters. Such data helps practices save money through proper E&M coding and reducing the need for transcriptions. Also this data increases opportunities for accurate reporting for patient management, research and diagnostic queuing.
SNOMED® and MEDCIN®
Two examples of standardized, codified data systems include the Systematized Nomenclature of Medicine (SNOMED) and MEDCIN®.
SNOMED is structured as a multi-axial classification system using alphanumeric codes. The system also incorporates most ICD-9 terms or codes, which facilitates reporting by these formats if needed.
Because of the way SNOMED concepts are created, the same note can be captured in a variety of ways. For instance, acute appendicitis may be noted as acute inflammation, in, Appendix; Acute, inflammation NOS, in, Appendix; or Appendicitis, acute, which can lead to difficulties when comparing concepts.
A nomenclature developed specifically to classify terms in clinical medicine is the MEDCIN® system. This product allows clinicians to relate notes on symptoms, history, exam findings, test results and therapies to the diagnosis and condition.
When incorporated into an EHR system encoded MEDCIN® data saves time charting, which allows more time for patient care. Another benefit is that codified data is available for reporting for items such as E&M codes and can lead to a dramatic increase in a practice’s income. In fact, the American Medical Association estimates that as many as 33% of visits may be under-coded by $27 or more1, so you can imagine the difference accurate coding can make.
Sage Software can help
The codified forms found within Sage Intergy EHR are based on the MEDCIN® database, which speeds documentation time and makes the data easy to query through built in reports or with detailed analytical tools like Sage Practice Analytics.
Documentation tools don’t stop there. Sage Intergy EHR allows for many types of input such as free form text, dictation and drawings in order to match each clinician’s preferences.
Ready to get started?
If you are ready to take the next step toward implementing Sage Intergy EHR in your practice, we’re here to help. Contact us to set up an onsite demonstration or receive additional information about Sage Intergy EHR.
1 Jewson Enterprises. (2007). The POMIS Report® - Trends and Events.
