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The quest for a single source of terminology truth

As federal regulatory initiatives up the ante on information sharing capabilities inside and outside a healthcare organization, the C-Suite is increasingly finding that a comprehensive terminology management strategy is critical.

Lack of a common clinical vocabulary across disparate systems is a primary roadblock to greater collaboration between payers and providers and the greater goals of health information exchange and accountable care.

Like many health systems, Wisconsin-based Dean Health Plan faced the challenge of managing code sets across numerous departments and disparate IT systems, each with their own inherent language and clinical terminology infrastructure. Largely governed by error-prone manual processes and workflows, the organization faced inevitable conflicts regarding terminology intake, management and distribution and lacked a formal process for governance and accountability.

Acquired by SSM Health Care in 2013, Dean Health encompasses three hospitals, 60 multispecialty physician clinics and a health plan covering 400,000 lives in the greater region of Madison, Wisconsin. The organization embarked on an enterprise terminology management initiative to prepare for the coming complexities of ICD-10 and lay a foundation for future growth within the larger integrated health network. This effort required a combination of advanced technology and governance to establish a single source of truth that would effectively manage and map data to industry standards and ensure accuracy across the enterprise.

Healthcare's terminology challenge

To effectively position for such high-level initiatives as ICD-10, Meaningful Use, population health management and analytics, providers, payers and other stakeholders along the healthcare continuum must overcome the challenge of sharing and using data across clinical care processes, business functions and systems. In fact, a 2012 Gartner report predicted the rapid evolution of this issue.

In "Top Actions for Healthcare Delivery Organization CIOS: Make Central Terminology Services a Cornerstone of Your Information Architecture," the research firm noted that the "next challenge is to interoperate with applications for analytics, quality measurement and collaboration," emphasizing that CIOs who once relied on EHR vendors to manage terminologies will have to assume direct responsibility for this function going forward. Unfortunately, for many resource-strapped healthcare organizations, terminology management is often characterized by manual, burdensome processes where code sets are managed across multiple departments and spreadsheets.

While the magnitude of the ICD-10 transition and its impact on coding and terminology management was a key driver, Dean Health also recognized the need for establishing a clear process for terminology intake, vetting and publishing throughout the organization. A process of internal discovery revealed that the organization was operating from 18 different code sets found within department silos--many containing outdated codes or value sets that were not in line with current policies. Issues over incorrect code use could already be traced to claims denials, and executive leaders were concerned about the potential for further liability.

With a coding team made up of only seven FTEs and no approved process in place, executive staff and clinical leaders identified the need for a centralized repository of up-to-date terminologies, maps and code sets to power interoperability, increase efficiency and reduce administrative overhead. The new system would have to address current challenges with acquisition, management and distribution of terminologies. Specifically, a governance process for aligning code group definitions and resolving discrepancies would have to be put into place as well as a transparent system for updating terminologies and increasing accountability for accuracy.

Enterprise terminology management

With the primary objective being consistency of information across the organization, Dean Health set out to establish a governance model for a terminology center of excellence. The initiative would cover five domains.

Policy and Governance: Govern alignment of terminology definitions, their intended use, versioning, and implementation across the enterprise.

Acquisition and Promotion: Validate and prioritize use of industry terminology standards (ICD-10, SNOMED CT®, LOINC®, etc.) and custom content.

Integration and Distribution: Ensure the implementation of terminologies within defined SLAs, supported by change notifications and auditing processes.

Content Authoring: Establish consistent governance over local content creation through a common information model that defines content structure and import requirements for modeling, mapping, and loading local terminologies.

Code Group Management: Identify and establish enterprise-wide business rules, and align these rules through code group management covering such areas as benefit policies, cohort identification rules, quality measures, and other classifications of clinical data for analytics.

Alongside the governance strategy, Dean Health deployed an enterprise terminology management platform to increase the efficiency and effectiveness of the process. The Health Language enterprise terminology management infrastructure provides a foundation of standard and enhanced terminologies, mappings, value sets, and synonym libraries. Software automates the process of terminology access, management, and distribution, and project-based workflow tools enable import, modeling, mapping, customization, grouping, and publishing of terminologies.

Critical to the choice for a terminology management solution was its ability to integrate with the broader organization's EPIC EHR. The implementation team also determined that an automated process for updating code definitions as industry standards changed was also a priority.

While there was some initial pushback to the new workflow, once staff realized the capabilities of the technological infrastructure and the advantages of a centralized source of terminology truth, many wanted to move faster than the implementation team's timeline. Wisdom and experience of previous IT rollouts dictated that adequate time would be necessary to educate staff and achieve success with the initial objectives.

Since initial implementation in 2014, Dean Health is experiencing better coding coordination between clinical and operational teams and better engagement from data governance teams. Workloads for coding practice leads will be substantially reduced, allowing more high-level use of professional resources for analysis.

As the quality-driven regulatory landscape continues to evolve, the new system of enterprise terminology management has positioned Dean Health to mature its information sharing and analytics capabilities for increased efficiencies and higher quality care delivery.

Tom Winchell is a program manager at Dean Health.

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