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International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records

There have been increasing calls for clinicians to document social determinants of health (SDOH) in electronic health records (EHRs). One potential source of SDOH in the EHRs is in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes (Z55–Z65). In F...

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Autores principales: Guo, Yi, Chen, Zhaoyi, Xu, Ke, George, Thomas J., Wu, Yonghui, Hogan, William, Shenkman, Elizabeth A., Bian, Jiang
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769291/
https://www.ncbi.nlm.nih.gov/pubmed/33350768
http://dx.doi.org/10.1097/MD.0000000000023818
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author Guo, Yi
Chen, Zhaoyi
Xu, Ke
George, Thomas J.
Wu, Yonghui
Hogan, William
Shenkman, Elizabeth A.
Bian, Jiang
author_facet Guo, Yi
Chen, Zhaoyi
Xu, Ke
George, Thomas J.
Wu, Yonghui
Hogan, William
Shenkman, Elizabeth A.
Bian, Jiang
author_sort Guo, Yi
collection PubMed
description There have been increasing calls for clinicians to document social determinants of health (SDOH) in electronic health records (EHRs). One potential source of SDOH in the EHRs is in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes (Z55–Z65). In February 2018, ICD-10-CM Official Guidelines for Coding and Reporting approved that all clinicians, not just the physicians, involved in the care of a patient can document SDOH using these Z codes. To examine the utilization rate of the ICD-10-CM Z codes using data from a large network of EHRs. We conducted a retrospective analysis of EHR data between 2015 to 2018 in the OneFlorida Clinical Research Consortium, 1 of the 13 Clinical Data Research Networks funded by Patient-Centered Outcomes Research Institute. We calculated the Z code utilization rate at both the encounter and patient levels. We found a low rate of utilization for these Z codes (270.61 per 100,000 at the encounter level and 2.03% at the patient level). We also found that the rate of utilization for these Z codes increased (from 255.62 to 292.79 per 100,000) since the official approval of Z code reporting from all clinicians by the American Hospital Association Coding Clinic and ICD-10-CM Official Guidelines for Coding and Reporting became effective in February 2018. The SDOH Z codes are rarely used by clinicians. Providing clear guidelines and incentives for documenting the Z codes can promote their use in EHRs. Improvements in the EHR systems are probably needed to better document SDOH.
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spelling pubmed-77692912020-12-29 International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records Guo, Yi Chen, Zhaoyi Xu, Ke George, Thomas J. Wu, Yonghui Hogan, William Shenkman, Elizabeth A. Bian, Jiang Medicine (Baltimore) 6600 There have been increasing calls for clinicians to document social determinants of health (SDOH) in electronic health records (EHRs). One potential source of SDOH in the EHRs is in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes (Z55–Z65). In February 2018, ICD-10-CM Official Guidelines for Coding and Reporting approved that all clinicians, not just the physicians, involved in the care of a patient can document SDOH using these Z codes. To examine the utilization rate of the ICD-10-CM Z codes using data from a large network of EHRs. We conducted a retrospective analysis of EHR data between 2015 to 2018 in the OneFlorida Clinical Research Consortium, 1 of the 13 Clinical Data Research Networks funded by Patient-Centered Outcomes Research Institute. We calculated the Z code utilization rate at both the encounter and patient levels. We found a low rate of utilization for these Z codes (270.61 per 100,000 at the encounter level and 2.03% at the patient level). We also found that the rate of utilization for these Z codes increased (from 255.62 to 292.79 per 100,000) since the official approval of Z code reporting from all clinicians by the American Hospital Association Coding Clinic and ICD-10-CM Official Guidelines for Coding and Reporting became effective in February 2018. The SDOH Z codes are rarely used by clinicians. Providing clear guidelines and incentives for documenting the Z codes can promote their use in EHRs. Improvements in the EHR systems are probably needed to better document SDOH. Lippincott Williams & Wilkins 2020-12-24 /pmc/articles/PMC7769291/ /pubmed/33350768 http://dx.doi.org/10.1097/MD.0000000000023818 Text en Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc. http://creativecommons.org/licenses/by-nc-nd/4.0 This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0
spellingShingle 6600
Guo, Yi
Chen, Zhaoyi
Xu, Ke
George, Thomas J.
Wu, Yonghui
Hogan, William
Shenkman, Elizabeth A.
Bian, Jiang
International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title_full International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title_fullStr International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title_full_unstemmed International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title_short International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records
title_sort international classification of diseases, tenth revision, clinical modification social determinants of health codes are poorly used in electronic health records
topic 6600
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769291/
https://www.ncbi.nlm.nih.gov/pubmed/33350768
http://dx.doi.org/10.1097/MD.0000000000023818
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