Healthcare has never been more complex than it is today. There has been a rapid expansion of medical treatment options, increasingly stringent regulatory requirements, and an ever-evolving landscape of medical coding, billing, and reimbursement. The burden of navigating this complexity has shifted significantly—and, some may argue, unfairly—onto medical providers. This shift has led to widespread dissatisfaction across specialties.
As the demands on physicians increase, so does the need for efficiency and accuracy in clinical documentation to ensure precise billing and timely reimbursement. This is particularly true for specialty practices, where the complexities of patient conditions and treatments require more tailored documentation approaches. For these practices, adopting an electronic health record (EHR) system specifically designed to meet their unique needs is no longer a matter of choice—it’s an essential step toward sustainability and success¹.
Specificity and Accuracy in Documentation
Specialty practices, such as dermatology, face unique challenges regarding documentation. Unlike general practices, they manage complex conditions, specifically focusing on an organ system, requiring specialty-specific and detailed descriptions of patient findings. For example, dermatologists must document specific anatomical locations, lesion types, and relevant clinical nuances—details often lacking in EHRs designed for general practitioners or different specialties. The transition from the International Classification of Diseases, 9th revision (ICD-9) to the International Classification of Diseases, 10th revision (ICD-10) has only increased the demand for specificity in documentation. However, generic EHR systems may not offer the detail needed to capture these complexities¹.
A specialty EHR system should provide the capacity to document with a high degree of granularity. It should incorporate detailed anatomical maps or templates specific to the specialty, which help clinicians capture precise information at the point of care. This specificity is not merely for completeness but has real-world implications for patient outcomes and financial health. Studies have shown that inaccurate or incomplete documentation can lead to coding errors, directly affecting reimbursement rates and causing payment delays².
Importance of Flexibility in Clinical Decision-Making
Medical providers face a significant challenge: they must accurately reflect their clinical findings in their notes while simultaneously translating these findings into billing codes. This becomes a difficult task more often than not, as tools designed for one purpose are not always adequate for the other. This creates a chasm between two opposing interests in medical documentation: clinical accuracy versus coding and billing requirements.
The most telling example of this conflict is the comparison between ICD-10 and Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT). The significantly larger number of concepts in SNOMED CT (over 350,000) reflects its purpose for detailed clinical documentation and its ability to capture the full complexity of patient care. In contrast, ICD-10 is more streamlined, with approximately 70,000 total codes, and is focused on specific uses like billing and reporting. Designed primarily for billing, reimbursement, and statistical purposes, ICD-10 classifies diseases and health conditions into a hierarchical structure for administrative use, such as insurance claims processing and public health reporting. While ICD-10 is effective for its intended purpose, it can be restrictive in capturing the nuanced details necessary for high-quality clinical care, particularly in medical specialties³.
SNOMED CT , on the other hand, is designed for clinical documentation and communication, aligning more closely with clinicians’ needs. It provides comprehensive, multilingual healthcare terminology that allows for detailed patient data recording. This extensive terminology system supports healthcare professionals in documenting clinical information in a structured and meaningful way³.
Given these differences, specialty EHRs must provide the flexibility to reconcile these two opposing interests—a balance that ensures accurate medical documentation and efficient billing, resulting in timely reimbursement. In specialty practices, clinical decision-making is rarely linear, as constrained by ICD-10 or comparable to those of other specialties; conditions and treatment plans frequently change based on patient response and evolving clinical evidence. Therefore, an effective EHR must allow providers to document these adjustments seamlessly³.
This is where including a terminology system like SNOMED CT becomes invaluable. Unlike ICD-10, primarily designed for billing and research purposes, SNOMED CT allows for more precise clinical documentation. It captures clinical nuances that may not translate directly into ICD-10 codes but are essential for delivering high-quality care. An EHR that supports SNOMED CT enables providers to document with clinical accuracy and then translate this information into the correct ICD-10 codes for billing purposes, ensuring that practices are reimbursed accurately and promptly for the care they provide³.
Seamless Integration of Coding Systems
A specialty EHR should seamlessly convert clinical documentation into standardized diagnostic (ICD-10) and current procedural terminology (CPT) codes with minimal provider input. One approach is textual input, but in dermatology, interacting with 3D anatomical maps that “understand” the context of each anatomical location in clinical, therapeutic, and billing terms is also utilized. This interaction significantly reduces the required steps for these complex tasks, supporting accurate billing and minimizing claim denials. According to recent data from the American Medical Association, nearly 10% of all medical claims are denied on the first submission, with coding errors significantly contributing to these denials². By accurately translating clinical notes into billing codes, specialty EHRs can reduce denial rates and improve the practice’s financial health².
Enhanced Workflow Efficiency and Provider Satisfaction
Research has shown that EHR usability directly impacts provider satisfaction. In a survey by the American Medical Association, over 50% of physicians reported that poor EHR usability contributes to burnout⁴. This is where specialty EHRs, designed with specific workflows in mind, can reduce the administrative burden on providers, help prevent burnout, and improve job satisfaction.
Workflow efficiency is another essential feature of a specialty EHR. Specialty practices often have unique workflows that differ significantly from general practitioners. For example, in a dermatology practice, providers may see fifty or more patients daily, necessitating efficient, accurate, and predictable documentation of patient encounters.
An EHR designed for these workflows can save time by automating repetitive tasks and streamlining data entry. Close integration with a practice management system—preferably provided by the same vendor—ensures billing data is captured and submitted to insurance companies for payment seamlessly⁴.
The Role of Artificial Intelligence (AI) in Enhancing EHR Functionality
Artificial Intelligence (AI) has the potential to revolutionize how specialty practices use EHRs by further enhancing their functionality and usability. AI can automate routine tasks such as data entry, appointment scheduling, and billing, thereby reducing administrative burdens and allowing providers to focus more on patient care. Machine learning algorithms can analyze vast amounts of clinical data to support decisions, suggesting potential diagnoses or treatment options based on similar cases. AI-driven natural language processing (NLP) can facilitate more accurate and comprehensive clinical documentation by interpreting free-text notes and converting them into structured data. Additionally, AI can continuously learn from data patterns to identify potential coding errors or discrepancies before claims are submitted, significantly reducing the likelihood of denials. By integrating AI into specialty EHRs, practices can optimize workflow efficiency, improve clinical decision-making, and ensure a higher level of care while enhancing financial outcomes.
Conclusion
In today’s increasingly complex healthcare environment, specialty practices require an EHR system tailored to their unique needs. Such systems are vital not only for maintaining clinical accuracy but also for achieving financial sustainability. A specialty EHR that integrates detailed documentation requirements supports flexible clinical decision-making, and facilitates seamless coding and billing can greatly enhance practice efficiency. Moreover, incorporating advanced technologies like AI can further optimize these systems, helping automate routine tasks, reduce administrative burdens, and minimize coding errors that lead to claim denials. Adopting a specialty-specific EHR allows practices to capture the total value of their care, ensuring they receive accurate reimbursements, enhancing provider satisfaction, and enabling a higher standard of patient care.
By leveraging the right technology, specialty practices can more effectively navigate the complexities of modern healthcare, improving clinical and financial outcomes. In a landscape marked by rapid change and increasing demands, an EHR designed just for them isn’t merely a tool—it’s an essential strategy for long-term success.
About Dr. Srdjan Prodanovich
Dr. Srdjan Prodanovich, a board-certified dermatologist, is the creator of EZDERM, a software designed to meet the unique needs of dermatology practices through advanced coding algorithms and precise documentation tools.
References:
- Association of American Medical Colleges. (2023). Out of the Shadows: Physicians Share Their Mental Health Struggles. Available at AAMC website.
- American Medical Association. (2023). Administrative Simplification: Improving Accuracy in Medical Billing. Available at AMA website.
- Cimino, J. J., et al. (2020). The Inadequacies of ICD-10 for Clinical Documentation and the Role of SNOMED CT. Journal of the American Medical Informatics Association, 27(3), 524-533.
- American Medical Association. (2018). AMA Digital Health Study: Physicians’ Motivations and Requirements for Adopting Digital Health. Available at AMA website.
