Contemporary issue in adopting of use of ICD10 [FOR DISEASES] and ICD10-PCS [for the 16 Newly Categorised Clinical Procedures] For Clinical coding and Health Statistical Reporting
By Prince Adefemi Adesida:
When a physician evaluate a patient, the physician collects subjective and objective data (the “history and physical”) to diagnose the patient’s condition and develop a plan for treatment. The most widely used diagnostic taxonomy in health care is the World Health Organization’s International Statistical Classification of Disease and Related Health Problems (ICD). The ICD is for coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances, procedures and external causes of injury or diseases used internationally to classify morbidity and mortality data for vital health statistics tracking and in the health insurance claim reimbursement. As medical advances continue, public reporting of quality indicators has become more prevalent, with greater emphasis placed on payment for quality. The use of ICD for the coding of hospital discharge (morbidity) or death certificate (mortality) data, using the rules established by WHO, ensure data which is comparable between individual hospitals, communities, states or internally , as well as at different points in time. Hitherto, the ICD-9-CM procedural coding system for coding operations was in use and this has now become obsolete and must be replaced. It was designed and implemented over 20 years ago, and since that time dramatic advances in medicine and medical technology have occurred that were not anticipated and not been adequately accommodated.
Consequently, over these years, the ICD system has outgrown its intended level of specificity and affects the ability to compare data precisely for clinical, research, and payment purposes as classification system is unable to accommodate yearly updates and advances in medicine and technology. This has necessitated the development of ICD-10 (Diagnosis) and ICD-10-PCS (Procedure Coding System). Right now, all countries are putting in enormous effort to meet the “TARGET -18 (2018 has been set by WHO when all countries should start to use new ways to clinical coding ICD-10 for diagnosis and ICD-10-PCS newly categorized clinical procedures” of the Word Health. The first step is passing a Bill setting a date and conducting an ICD-10 Awareness and Readiness Assessment and actually setting a date ahead of the TARGET 18 date as it has been done in many Countries that have started the compliance process.
ELECTRONIC HEALTH RECORDS A MUST FOR SMART HOSPITALS IN THE 21st CENTURY In developing world, the Health Facilities generally are such that medical transactions are mostly manually processed using a paper-based system, which is far from ideal thereby making the health Data and Information generally of low validity. There is the need for automation of processes so as to make it easy to provide rapid interaction and access to patient information on the terminal and at the same time guarantees preservation of medical logic, as care is problem-oriented. In addition it will provide information on the screen in variety of ways – by problem, chronology across all problems or by source e.g. Laboratory, radiology and also makes it easy to conduct audit and review of patient records.
Other areas of focus in using software includes where trending information is automatically transferred from a lodox equipment into an electronic health record (EHR). Doctors can view data directly from such equipment, identify more spontaneous breathing, and consult with the respira¬tory therapist regarding a weaning protocol, all with¬out ever having to call the nurse or visit the patient. This has long been a possibility, but is now becom¬ing a reality. Hospitals are seeing data pulled from medical devices such as physiologic monitors, vital signs monitors, ventilators and infusion pumps and transferred automatically into the EHR. Unfortunately, this is not as easy as inserting a plug into a computer. This is where medical device connectivity solutions come into play. They allow data to be transferred from the medical device to the EHR, while solving such issues as information mapping and patient asso¬ciation/disassociation intended to be medical device – and EHR vendor-neutral. This can be advantageous because we would man¬age the interfaces between the medical device data and the EHR system, rather than requiring the facility to manage mul¬tiple interfaces for each type of medical device.
HEALTH, SAFETY & ENVIRONMENT [HSE] DATABASES INCORPORATING CODING WITH ICD10 [FOR ACCIDENTS & EXTERNAL CAUSES] AND ICD10-PCS [FOR BODY SYSTEMS & PARTS/INTERVENTION PROCEDURES]- FOR NOTIFICATION FOR LABOR SAFETY, HEALTH SURVEILLANCE AND COMPENSATION. An accident is an event independent of the will of man caused by quickly acting extraneous force and manifesting itself by producing unintended injury, death or property damage. Today, our work continues to define who we are in large measure and doing a job, whatever the job, is a central part of one’s life. We take it for granted that when we go to work, we will not be injured, made sick, or killed. Many traditional hazards of work such as traumatic injuries no longer take the toll they once did, but they still persist. Emerging technologies raise concerns about potential risks that, as yet, may not be well understood or quantified. For example, as domestic and international markets for nanotechnology grow, society increasingly recognizes that the occupational health and safety implications of engineered nano-materials must be evaluated, and precautionary principles applied. The changing dynamics of the work environment and the changing demographics of the work force pose similar concerns. Knowing that the health and safety needs of the increasingly diverse workforce differ from those of the predominantly male workforce of the 20th Century, we are challenged to find ways to meet those needs.