Note from the Associate Editorial Director: Clear, concise, precise use of language

by Melissa Varnavas

“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a few years ago, and remember chuckling at the best and worst examples of effective communication.

Most CDI professionals no doubt would be surprised that an organization such as The Center for Plain Language exists. Many would also find it surprising to learn that President Barack Obama signed The Plain Writing Act of 2010 into law back in October and that the Office of Management and Budget recently drafted preliminary guidance for implementation of the new legislation. The law “requires the federal government to write all new publications, forms, and publicly distributed documents in a ‘clear, concise, well-organized’ manner that follows the best practices of plain language writing.”

The idea, of course, is that a well-informed public can better abide by, and influence promulgation of, the rules and regulations of their society. Such an ideal seems simple enough, and worthy enough, yet when applied to the profession of CDI, the complicated nature of this endeavor reveals itself.

Let me explain.

At its most elemental, the CDI specialist serves as translator between healthcare’s clinical and coding languages. Each of these languages has developed over many decades and is complete with its own rules and nuances of use.

Physicians spend in excess of 10 years of schooling learning the language of the body’s processes and the latinate words we use to describe those processes. What cardiologists are able to quickly communicate to each other may not be as easily understood if, for example, a cardiologist attempted to communicate a clinical scenario with a nephrologist. The language each type of physician uses may be precise to his or her own awareness of the conditions and according to the familiarity of how those words and phrases are used in their daily lives.

Although the language of medical coding may not have its history rooted in ancient Greek, it nevertheless dates back to the early 1800s when the first International List of Causes of Death (then called the Bertillon Classification of Causes of Death) was adopted by the International Statistical Institute at a meeting in Chicago, according to The HIM Director’s Guide to ICD-10. Since then, the International Classification of Diseases (ICD) has evolved through 10 revisions and contains not only more than 150,000 codes, but multiple details of instructions in the Official Guidelines for Coding and Reporting regarding the application of those codes.

Add to all this the complexity of transmitting the coded elements of healthcare information electronically to a variety of entities, including research agencies, government and private payers, physicians, and yes, sometimes even to the patients themselves. To do this, the American National Standards Institute (ANSI) Transaction Version 5010 and National Council for Prescription Drug Programs (NCPDP) Version DO and 3.0 needs to be implemented, which includes more than 850 structural, technical, and content changes to the current system.

Where is the simplicity of “plain language”?

Bear with me, please, as I am not quite done outlining the complexity of dialogue which currently governs our healthcare system. In several recent conversations, CDI professionals have expressed their frustration with CDI involvement in the planning for, and implementation of, electronic health records.

Depending on how precise your awareness is of this process, you may not know, for example, that an electronic health record (EHR) is not the same thing as an electronic medical record (EMR). An EHR is the global term encompassing all electronically-generated components of a computer-based patient record. It generally refers to hospital- or facility-based records, as opposed to the EMR, which is the global term encompassing all electronically-generated components of a computer-based patient record—generally refers to physician-, professional-, or clinic-based records. (Read more on these definitions in a previous blog post.)

All of this would (could? should? does?) make the indoctrinated individual’s mind recoil at the complexity of it all. And yet, this is the world CDI specialists enter every day as they attempt to translate missing or vague physician documentation into as precise a collection of words as possible to illustrate the clinical condition of the patients under their purview.

Every year, The Center for Plain Language calls for nominations for its ClearMark Award. Unfortunately, CDI as a profession would not be eligible. I am sure, however, that those in this field labor to follow the Center’s basic premise that:

• “Plain language is information that is focused on readers. When you write in plain language, you create information that works well for the people who use it, whether online or in print.
• Plain language is behavioral: Can the people who are the audience for the material quickly and easily find what they need, understand what they find, and act appropriately on that understanding?”

At its best, a well-implemented CDI program will help the physician use plain and precise language throughout the medical record so that everyone who needs to use that information—from nurses to coders, from IT to billing, and even from physicians to their patients—can understand and use that information.

Editor's note: Varnavas is the associate editorial director of ACDIS. Contact her at mvarnavas@acdis.org.