EHR and autonomous coding: Why both?

Aug. 20, 2024 / By Diana Ortiz

Autonomous coding is a big buzzword these days, especially as coders are asked to do more with less time and fewer resources. What exactly is autonomous coding and how does it work with electronic health records (EHRs)? 

Achieving autonomous coding has been quite the journey. Coders started out using coding books and eventually moved into solutions that gave them insights in more real time, so they didn’t have to go look things up manually. With the implementation of ICD-10, there was a big shift towards computer-assisted coding (CAC) in the industry, being able to auto suggest codes to help achieve the correct code. Automation is the next step, and what that really means is being able to automate an entire visit, every code, at an accurate level without a human touch.  

So, where does the EHR fit in? EHRs are the keepers of the entire medical record, with all the documentation and data flowing into them.  Sometimes there are capabilities within EHRs to do what’s called “simple visit coding” or coding things that have a primary connection between an order and code assignment. This is certainly a beginning point on the journey towards automation.  

Being able to expand coding automation to more coding service lines requires leveraging all the documentation and information from the EHR to generate accurate and compliant codes.  It is critical to compliance, to be able to account for the constant medical innovation, and how it is represented in regulatory and coding updates.  The ability to maintain and automatically apply the regulatory guidelines to code automation is critical to ensuring accuracy while achieving new efficiencies.  Achieving automation through the lens of compliance is really important when considering how you operationalize something, in addition to leveraging what the EHR can supply. 

For even better connection within the EHR, we are excited to announce that our autonomous coding solution has received the Toolbox designation from Epic Corporation in the Fully Autonomous Coding category! Toolbox is a designation for products using established integration technologies in specific categories that meet Epic’s recommended connection pattern. In addition, Solventum’s ambient clinical documentation solution can be found in the Connection Hub on the Epic Showroom.  

We have integrated our solutions with Epic for more than two decades. We are excited to further integrate and build on Solventum’s long-standing expertise. This will provide a more streamlined implementation, usage and overall integration for our customers.  

Join my first podcast episode to learn more about coding automation and the EHR. 

Diana Ortiz, senior business director of revenue cycle, Solventum.