2021 ICD-10CM Update Effective October 1,2020

One of the biggest changes to our ICD-10-CM books for the upcoming new year will be the addition of Chapter 22: Codes for special Purposes (U00-U85). Although this new chapter only consists of two codes and these codes were actually created and valid as early as April 2020, the creation of this chapter is proof that lessons from our current pandemic have been learned. nnHere are the codes, and their guidelines as printed in the Official ICD-10-CM FY 2021 Guidelines;

ICD-10 2021 Updates

The ICD-10 2021 updates include over 500 significant changes. These updates, set to take effect on October 1, 2020, include 490 new codes, 47 revised codes, and 58 codes deemed invalid. We will also see increased instructions on reporting manifestations of COVID-19. New guidance on social determinants of health, insulin use & acute kidney failure. See Welter Healthcare Partners’s summary of these changes in the information below!nnWith over 500 diagnosis coding changes just around the corner, the FY 2021 ICD10CM Official Guidelines bring updates that are set to be significantly larger than the FY2020 update brought to us last year.nnUpdates that are set to take effect October 1st, 2020 include 490 new codes, 47 revised codes and 58 codes deemed invalid (see table below), additional instructions on reporting manifestations of COVID-19, as well as new guidance on social determinants of health, insulin use and acute kidney failure, among several other changes.nnBelow is a summary of the anticipated FY2021 ICD10CM Updates by Chapter:nnChapter 1: Certain Infectious & Parasitic Disease brings a new section 1.g for reporting Coronavirus infections.nnChapter 3: Diseases of Blood & Blood-forming organs has eighteen new, detailed codes available for sickle cell anemia. These new codes describe complications associated with sickle- cell and hemoglobin-C (Hb-C) diseases. For example, a note for new sickle-cell thalassemia code D57.418 (Sickle-cell thalassemia, unspecified, with crisis with other specified complication) instructs the coder to code any identified complications such as cholelithiasis (K80.-) or priapism (N48.32).nnChapter 4: Endocrine, Nutritional & Metabolic Disease includes new coding instructions to follow for diabetic patients treated with insulin, oral hypoglycemics and injectable non-insulin drugs. For example, if the patient is taking both insulin and an injectable non-insulin antidiabetic drug, assign both Z79.4 (Long term [current] use of insulin) and Z79.899 (Other long term [current] drug therapy). If the patient is taking oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign code Z79.84 (Long term [current] use of oral hypoglycemic drugs) in addition to code Z79.899.nnChapter 5: Mental, Behavioral and Neurodevelopmental Disorders contains twenty-one new codes that describe withdrawal from substances including alcohol, cocaine, and opioids. For example, F10.932 (Alcohol use, unspecified with withdrawal with perceptual disturbance).nnChapter 6: Diseases of the Nervous System has added “pseudotumor” as a clarifying term to G93.2 (Benign intracranial hypertension) and coders are instructed to code G98.81- (intracranial hypotension) with G96.0 (Cerebrospinal fluid leak) when applicable.nnChapter 9: Diseases of the Circulatory System contains many revisions to the includes and excludes notes for existing codes. For example: Atherosclerosis of native arteries of the legs with ulceration (I70.2-) now includes both critical and chronic ischemia of native arteries with ulceration. Hypertensive Heart Disease (I11) has been revised to exclude Takotsubo Syndrome (I51.81), also known as “broken heart” syndrome.nnA new hypertension guideline provides instruction that when a patient has hypertensive chronic kidney disease and acute renal failure, code both conditions and sequence the codes based on the reason for the encounter.nnChapter 10: Diseases of the Respiratory System now has code also instructions for cases of acute laryngitis and tracheitis (J04) and acute obstructive laryngitis (croup) and epiglottitis (J05). Coders are instructed to code also influenza if present, including influenza due to identified novel influenza A virus with other respiratory manifestations (J10.1). This chapter also has a new section 10.e specifically for vaping-related disorders.nnChapter 13: Musculoskeletal System found several updates this year including twelve new codes to capture other pathological fractures (M80.8AX- and M80.0AX-). Updates include an expanded list of codes for rheumatoid arthritis, as well as primary and secondary arthritis, and arthritis caused by trauma. New codes in the M24 category for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture and ankylosis.nnChapter 14: Disease of Genitourinary brings two new sub-stages to Stage 3 chronic kidney disease (CKD). The new codes are: N18.30 (Chronic kidney disease, stage 3 unspecified), N18.31 (Chronic kidney disease, stage 3a) and N18.32 (Chronic kidney disease, stage 3b).nnChapter 15: Pregnancy, Childbirth and the Puerperium contains new language that warns coders they should not report O85 for sepsis that follows an obstetrical procedure. A notenpoints them to the Sepsis due to a postprocedural infection of Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99), U07.1.nnA new section 15.s provides instruction on reporting COVID-19 infections in pregnancy, childbirth, and the puerperium. E.g. when a newborn tests positive for COVID-19 and the provider has not documented a specific method of transmission, assign code U07.1 and the appropriate codes for associated manifestations. Code P35.8 (Other congenital viral diseases) followed by U07.1 when the provider documents that the newborn contracted the disease in utero or during birth.nnChapter 16: Certain Conditions Originating in the Perinatal Period has a new section 16.h for reporting COVID-19 Infections in Newborn.nnChapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains several changes. Code R51 (Headache) will be split into two codes: R51.0 (Headache with orthostatic component, not elsewhere classified) or R51.9 (Headache, unspecified).nnAnother source of new headache coding will come from five new codes for intracranial hypotension – the severe orthostatic headache that is a common symptom of a cerebral spinal fluid (CSF) leak: For example, G96.810 (Intracranial hypotension, unspecified), G97.83 (Intracranial hypotension following lumbar cerebrospinal fluid shunting) and G97.84 (Intracranial hypotension following other procedure). Five new codes for CSF leaks can now be found in place of the current code G96.0 (CSF leak).nnChapter 19: Injury, poisoning & certain other consequences holds 128 additions that include new codes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics.nnChapter 21: Factors influencing health status and contact with health services includes new observation language. The new language creates a second exception to the rule that observation codes are primary. The GL state, “An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis.”nnNEW Chapter 22: Codes for Special Purposes (U00-U85) includes just two codes: U07.0 Vaping- related disorder and U07.1 COVID-19, these codes took effect in the earlier this year.nDeletions from the 2021 ICD-10-CM code set include: Q51.20 (Other doubling of uterus, unspecified), and the entire code family of T40.4X- (Poisoning by adverse effect of and underdosing of other synthetic narcotics).nnThe general coding guidelines clarify that social determinants of health may be coded if self- reported by patients, “as long as the patient self-reported information is signed off by and incorporated into the health record by either a clinician or provider.” Social determinants of health, found in code categories Z55-Z65, report potential health hazards related to socioeconomic and psychosocial circumstances that may complicate the care of the patient (e.g., the patient is unemployed).nnReferencesnnInternational Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) nnICD-10-CM Official Guidelines for Coding and ReportingnnProposed 2021 ICD-10-CM update flashes nearly 500 new codes, additional changes 

Small Medical Practices to Benefit From Newly Proposed QPP Rule

Check out this article about small businesses and how they can benefit from an exemption from EHR requirements!Small Medical Practices to Benefit From Newly Proposed QPP Rule nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicad Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n


  1. Practices that bill less than $90,000 in Part B charges.
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  3. Practices that see fewer than 200 Medicare patients.
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nThese practices would be exempt from QPP requirements in 2018. Those figures are up from $30,000 in Part B charges and 100 Medicare patients in 2017.nnSmall practices, defined as having 15 or fewer eligible clinicians, also could add five points to their total performance scores in the merit-based incentive payment system (MIPS) “as long as the eligible clinician or group submits data on at least one performance category in the applicable performance period.” That would get them closer to the proposed 15-point performance threshold. Eligible providers that don’t fit within those categories would have to meet these QPP requirements to avoid a 5% cut, or potentially earn a 5% bonus in 2020, according to the proposed rule.n

Click Here To Read More

nThis article was originally posted on HealthMediaLeaders.com

New Obstacles Arise For the Electronic Health Record Market

Big Data and Analytics Encounter Roadblocks in the Form of EHR Costs

nNew Obstacles Arise For the Electronic Health Record MarketHospitals amassing more and more administrative, clinical, financial and ICD-10 data are looking to harness statistics, data science and mining tools and the electronic health record market is expanding but new obstacles are arising. nnThe predictive analytics market is gaining traction and driving EHR growth. But in something of a twist the costs of new EHR tools are simultaneously creating a significant barrier to big data and analytics, according to a new Research and Markets report.nnIndeed, as healthcare providers continue to amass copious amounts of healthcare data, including clinical, administrative and financial information as well as the shift from ICD-9 to ICD-10, are all leading healthcare organizations to implement analytics tools to make use of accrued data, according to the report.nnEHR adoption, meanwhile, is growing among healthcare providers, and the market will continue to expand at a CGR of 5.53 percent over the next four years, Research and Markets projected.nn“One trend impelling growth in this market is the increased adoption of predictive analytics,” one of the report’s analysts commented. “The ever increasing volume variety, and velocity of clinical and non-clinical data have compelled healthcare organizations to implement statistical tools, data science and mining technology.”nnBut implementation of healthcare information systems, encompassing EHR software, hardware and network installation costs, are also some of the greatest hindrances en route to a future of big data and predictive analytics, Research and Markets noted.nnWhat’s more, the extra hardware and software installation involved when integrating EHR systems with pharmacy and laboratory data may prove to be too expensive for smaller hospitals and providers in developing countries to put new analytics to work anytime soon, the report said.nnThis article was originally posted on HealthCareITNews.com.

Alternative Payment Models For Healthcare Industry

Federal Agencies adopt new tactics for healthcare industry to alternative payment models in medicine.

nAlternative Payment Models For Healthcare Industry The Department of Health and Human Services has pushed forward several alternative payment models for the healthcare industry.nnIn recent years, the federal government has positioned the healthcare industry to adopt new reimbursement tactics aimed at strengthening pay-for-performance initiatives. These regulations consist of alternative payment models such as bundled payments or value-based care reimbursement. The Centers for Medicare & Medicaid Services (CMS), for instance, established the Comprehensive Care for Joint Replacement Model, which consists of implementing bundled payments or reimbursement based on an episode of care within hip and knee replacement surgeries.The proposed rule for the bundled payment model was initially was published on July 9, 2015 and the finalized legislation was made available on November 16, 2015. The start date of the Comprehensive Care for Joint Replacement Model is set for April 1, 2016. “The CJR [Comprehensive Care for Joint Replacement] model holds participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers,” CMS stated on its website.nn“The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities) and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.” CMS has had a rich history of supporting bundled payment models starting in the 1980s when an inpatient prospective payment system was created. This was the first step in which the Medicare program reimbursed hospitals based on a fixed amount for each patient’s hospital stay and diagnosis.n

Click Here to Read More

nThis article is originally posted on Revcycleintelligence.com.


 nn nnBilling/Accounts Receivables/Revenue Cycle Management:  The blood that keeps a practice alive:nnPick a patient seen one month ago and follow that revenue cycle.  Look at the claim, compare it to the notes, has it been paid?  Did the patient pay a co-payment or deductible if so when? (Co-payments and deductibles should be paid at the time of service).  Did the insurance pay, if a clean claim was sent electronically it should be paid within 30 days. Was it paid properly? How do you know?   If it hasn’t been paid, find out why!  Revenue Cycle is a Cycle!  Follow it!  You may be surprised at what you find.nn 


 nn nnPlease, do not feed the wildlife…nS61.451A: Open bite of right hand, initial encounternW55.81XA: Bitten by mountain lionnY93.01: Activity, hikingnn 

Welter Healthcare Partners Renews Contract With Colorado Department Of Public Health

Screen Shot 2014-03-21 at 11.37.53 AM Welter Healthcare Partners is proud to announce that we’ve received approval to renew our contract with the State of Colorado Department of Public Health and Environment. We will continue to assist with medical clinics covering the topics of:n


  • Billing
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  • Coding
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  • Managed care contracting
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n Welter Healthcare Partners is currently working with local public health agencies and state and national public health leaders to address these issues. We are actively assisting large and small public health departments across the country by providing:n


  • Comprehensive assessments of current capacity, structure, resources, systems and personnel with recommendations for moving forward
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  • Strategic planning and implementation services
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  • Revenue cycle management
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  • Billing and A/R management services
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  • Insurance contracting and credentialing
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  • Provider coding and documentation training, including ICD-10 training
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  • Practice management and electronic medical records (EMR) implementation
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nCheck out page 31 of the January/February publication of Colorado Medicine, below, which features an article covering the work of our own Todd Welter!nn

ICD-10 Coffee Klatch Webinar

This ICD-10 Coffee Klatch webinar is an informative review and excellent starting point for physician and hospital coders. Ms. Toni Woods and Ms. Whitney Horton, both AHIMA-Approved ICD-10-CM/PCS Trainers, will give viewers a glimpse of Welter Healthcare Partners’s formal ICD-10 Coder Academies and training, and provide an overview of ICD-10 Coding Conventions, Chapter Guidelines, Code Structures and an introduction to the 31 root operations in the Medical and Surgical sections of ICD-10-PCS.nn

This interactive and hands-on ICD-10 training is designed to prepare coders for the AAPC and AHIMA ICD-10 proficiency examinations. Participants will gain the tools they need to appropriately select ICD-10-CM and ICD-10-PCS codes. These training sessions will be coder centric, and the content will be designed for those staff who will be responsible for applying (or verifying) these codes to documentation. Throughout the academy, participants will be given an assortment of scenarios to code to obtain the proficiency they need for coding in ICD-10. Participants only needing ICD-10-CM training (physician and outpatient coding) should register for the first day of the academy only (Day 1). Participants needing ICD-10-PCS training (hospital/inpatient coding) will need to register for the entire 3-day academy.n

Overview of ICD-10 Academy Agenda:

n(lunch, snacks and drinks will be provided each day) [twocol_one]ICD-10-CM (Day 1) AHIMA-approved ICD-10-CM/PCS trainers will educate coding staff regarding ICD-10-CM with a focus on:n


  • Convention changes and additions
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  • Concept changes and additions
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  • Chapter specific guideline changes and additions
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  • Live coding workshop
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n**This training has the approval of 8.0 CEU’s from the American Health Information Management Association (AHIMA) (AAPC members can submit these CEU’s to AAPC for credit) [/twocol_one] [twocol_one_last]ICD-10-PCS (Days 2 and 3) AHIMA-approved ICD-10-CM/PCS trainers will educate coding staff regarding ICD-10-PCS with a focus on:n


  • The structure of ICD-10-PCS text and codes
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  • The definition and application of each root operation
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  • The method by which an ICD-10-PCS code is selected
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  • Live coding workshops
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n **This training has the approval of 16.0 CEU’s from the American Health Information Management Association (AHIMA) (AAPC members can submit these CEU’s to AAPC for credit)nnClick here for detailed training agenda nn[toggle title_open=”Required Academy Materials:” title_closed=”Required Academy Materials:” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]AHIMA ICD-10-CM Coder Training Manual and/or AHIMA ICD-10-PCS Coder Training Manual – Upon registration participants Training Manuals (CM only, or CM/PCS for 3 day training) will be ordered on their behalf – cost is $75.00 per training manual (discounted from $100.00 per manual) and will be added to the registration fee.nnContexo ICD-10-CM (Draft) and/or ICD-10-PCS (Draft) – Upon registration participants coding manuals (CM only, or CM/PCS for 3 day training) will be ordered on their behalf – cost is $90.00 per ICD-10 book and will be added to the ration fee. ($180.00 for both CM and PCS books for the 3 day training) (Discounted from $110.00 per book)nn**Book Pick-Up: In order for pre-requisites to be completed prior to the actual course date, participants will be required to pick up their books from 8am – 5pm, at Welter Healthcare Partners headquarters at 6870 W. 52nd Avenue, Suite 102, Arvada, CO 80002 on:n


  • Friday, February 28, 2014 – for the March Coder Academy
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  • Friday, May 30, 2014 – for the June Coder Academy
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nIf you need to make alternative arrangements to pick up your books, please contact Jennifer at 303.534.0388.[/toggle]nn[toggle title_open=”Academy Pre-Requisites:” title_closed=”Academy Pre-Requisites:” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”][twocol_one]ICD-10-CM Only (day 1):nICD-10-CM Coder Training Manual: Pages 2-82; Reading and accompanying section review questions[/twocol_one] [twocol_one_last]ICD-10-CM-PCS (3 day academy):nICD-10-CM Coder Training Manual: Pages 2-82; Reading and accompanying section review questions and ICD-10-PCS Coder Training Manual: Pages 2-83; Reading and accompanying section review questions[/twocol_one_last][divider_flat][/toggle]nn[toggle title_open=”Academy Dates and Locations:” title_closed=”Academy Dates and Locations:” hide=”no” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”][threecol_one]Englewood, COnREGISTRATION DEADLINE MARCH 4thnMarch 12-14, 2014n8:00am – 5:00pmn(On 3/13/14 training will be held from 9:00am – 6:00pm)nSwedish Medical Center – Pine B & C Conference Roomn501 E. Hampden AvenuenEnglewood, CO 80113[/threecol_one] [threecol_one]Thornton, COnREGISTRATION DEADLINE May 30thnJune 11-13, 2014n8:00am – 5:00pmnSpine Education & Research Instituten9005 Grant Street, Suite 100nThornton, CO 80229[/threecol_one] [threecol_one_last]ONLINE (web-based) Coder AcademynREGISTRATION DEADLINE June 20thnJuly 8-10 2014n8:00am – 5:00pmnRegistered Participants will have webinar training details emailed to them 72 hours prior to the training.nnParticipant Training Books will be shipped 2 weeks before training. Please provide the address of where books should be shipped on the registration form.[/threecol_one_last][divider_flat] [/toggle]n

Academy Registration Fee:

nICD-10-CM Only (Day 1) – $275.00 per participant (plus $165.00 for the training manual and the ICD-10-CM book)nnICD-10-CM-PCS (3 Day Academy) – $800.00 per participant (plus $330.00 for the training manuals and the ICD-10-CM/PCS Books)n

Registration Discounts:

nPractices registering 3+ participants will receive $50.00 off each registration.n

Seating is limited, register now to guarantee your spot today!

nClick here for registration formn

Course Instructors:

nToni Woods, CPC and Whitney Horton, CPC, CCCnMs. Woods and Ms. Horton are AHIMA-Approved ICD-10-CM/PCS Trainers. They are educators and trainers in the areas of ICD-10, physician documentation, Medicare coding and documentation guidelines, ambulatory medicine coding, hospital, and other facility coding and documentation. They work with physician practices of all specialties and are experts in analyzing chart documentation and in reengineering practices to enhance their reimbursement systems and processes, and overall increase revenue and profitability. Their goal is to empower physicians and health care professionals and staff to understand the language of the coding and billing world, and to give them the tools they need for successful reporting and reimbursement of their services. Ms. Woods and Ms. Horton are enthusiastic about the future of ICD-10 and are on the forefront of providing ICD-10-CM/PCS education and implementation processes.

[gravityform id=”4″ name=”Free ICD-10 Seminars” title=”false” description=”false”]nn nn

nn[toggle title_open=”Close Me” title_closed=”Open Me” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”][gravityform id=”5″ name=”ICD-10 Seminars” title=”false” description=”false”][/toggle]

ICD-10 is Coming…. Don’t Be Left in the Dark!

ICD-10 is Coming…. Don’t Be Left in the Dark!Physician practices and hospitals may need up to 2 years to plan for and successfully implement ICD-10. With the implementation date set for October 1, 2014 (and multiple sources saying there will be no more delays!) it is important to start your education and training now! ICD-10 will bring monumental changes to all healthcare providers and facilities – failure to prepare will result in a significant decrease in revenues, cash flow and productivity!nn Welter Healthcare Partners ICD-10 training is facilitated by an AHIMA ICD-10-CM/PCS certified trainer with over 6 years of experience of ICD-10 training and education – for physicians and hospitals! Our ICD-10 training is comprehensive and fully customizable to meet your specific needs.nnFor more information about ICD-10 training for your practice or facility click here, or call us today at 303.534.0388 or 877.825.8272!

Could your new electronic medical record system be missing vital information the old paper-based system captured?nnEven the most seasoned technology champion has to stop and ask that question, if for no other reason than the new medical record looks very different than the old one. To put it in classroom terms, today’s EMR is often multiple-choice, not essay.nnBut almost as long as there have been doctors, the preferred way for them to communicate has been through a narrative—a story.nnEMRs may introduce gaps in that narrative, says Philip Resnik, professor of linguistics in the Institute for Advanced Computer Studies at the University of Maryland.nnSince 1999, Resnik’s been studying the limitations of entering clinical information into discrete fields and checkboxes in an EMR. At the recent South by Southwest conference, Resnik described the dilemma clinicians face: to embrace the EMR with all its limitations, or to push ahead for new technologies such as natural language processing that rarely see clinical use today.nnResnik illustrates the problem with a sample narrative of a woman complaining of shortness of breath. In a slide he highlights snippets that are easily entered into EMRs, such as symptoms and actions taken. But he also underscores much text that helps tell the story of the patient’s encounter in the ER but doesn’t readily map to fields in an EMR.nnn”The doctors in the ER were trying to figure out whether the shortness of breath in this woman was due exclusively to her failing heart, or was there a problem with pneumonia,” Resnik says. “People who have pneumonia do not respond promptly to [BiPAP] treatment. But she responded promptly. This gave them information.”nnResnik bets that few point-and-click EMRs have a check box or slider control for how quickly a patient responded to a treatment.nnText fields in EMRs can capture this information, but in a busy exam room, with doctors trying to point, click, and enter EMR data during the exam, while also trying to maintain eye contact with the patient, how much time will be left for text entry?nnThe dilemma compounds when you realize that any data entered in text fields will resist analysis. Database analysis works best with discrete numbers. So even if we get doctors to enter the portions of their narrative that don’t fit in discrete data fields, we’ve lost the ability to really analyze that data.nnAs an experiment, Resnik and some other researchers took 20 cardiology dictations and went through them manually, highlighting the info that could be placed in discrete fields, without having to type into a text box.nn”Then we took two cardiology experts and said, ‘Let’s pretend this clinical record is somebody a doctor across the country referred to you as a case,'” Resnik says. Researchers had highlighted info that couldn’t be placed in the discrete fields, and they asked the cardiologists to rate how severe a gap in the record the highlighted information was.nnnIn half the records, there was at least one thing the two doctors independently concluded should have been in the patient’s record.nnThe researchers did another experiment where they assumed that the EMR, which happened to be in use in British Columbia, could capture more of the narrative with some extra engineering.nnThe cardiologists still found a severe problem in one out of four records, Resnik says.nnAnother issue with EMRs is the advance of medical science. In the early 1990s, a higher-resolution CT scanner was introduced. Radiologists started discovering semi-opaque nodules in the lungs which indicated a much higher probability of lung cancer. But older medical records simply offered the choice of “opaque” or “transparent” and had no way of expressing the newer notion of “semi-opaque.”nnSuch examples must abound in medicine as it advances. How valuable will today’s EMRs be in tomorrow’s realities?nnThe traditional clinical narrative also has another set of nuances not present in the typical modern EMR. Narratives may say that something is “suggestive of” a particular condition without that condition actually being present. Patients may deny the presence of a particular condition, such as chest pain, but the EMR may not allow for such a denial to be a structured part of the record. In another example, doctors may agree that a particular pilot-as-patient should not be recertified to fly without undergoing a particular procedure.nnn”I have a feeling ‘Don’t recertify patient to fly without this procedure’ is not a check box that is easy to put into this medical record,” Resnik says.nnSymptoms also change over time, and EMRs may not be nearly as good as a narrative when expressing this.nnOn top of all these concerns, a generation of older clinicians who are used to simply narrating their records creates a recipe for a mass exodus of personnel on top of growing doctor shortages.nnResnik worries that with the current stampede to meaningful use, all these considerations are being ignored.nnAs somewhat of a salvation, work continues on natural language processing. Resnik, who consults in this field, notes that machines are making strikes in learning to read, parse, and code narratives, partly because of the recent move to “big data” and advances in machine learning such as IBM’s Watson project.nnIn other fields, including marketing and advertising, big data—the sophisticated analysis of very large data sets—is a big deal. Healthcare tech seems to be late to the game. Too many of today’s EMR solutions seem to be based on the old-style client/server technology of the 1990s.nnIn Resnik’s opinion, doctors shouldn’t be checking boxes while they’re trying to do a narrative. He says there are ways to “engineer the ergonomics” of the system. He, and I, think it’s time we do.