In my post on funny ICD-10 codes ruining the ICD-10 brand, I briefly commented how there’s no ICD-9 code for Ebola, but that there is one for ICD-10.
One more reason to finally implement ICD-10 in the US.
In my post on funny ICD-10 codes ruining the ICD-10 brand, I briefly commented how there’s no ICD-9 code for Ebola, but that there is one for ICD-10.
One more reason to finally implement ICD-10 in the US.
The following is a bit depressing, but shouldn’t come as a surprise. A new study published in the Journal of the American Medical Informatics Association has concluded that patient safety issues relate to EMR rollouts continue long after the EMR has been implemented, according to a report in iHealthBeat.
Now, it’s worth noting that the study focused solely on the Veterans Health Administration’s EMR, which doubtless has quirks of its own. That being said, the analysis is worth a look.
To do the study, researchers used the Veterans Health Administration’s Informatics Patient Safety Office, which has tracked EMR safety issues since the VA’s EMR was implemented in 1999. Researchers chose 100 closed patient safety investigations related to the EMR that took place between August 2009 and May 2013, which covered 344 incidents.
Researchers analyzed not only safety problems related to EMR technology, but also human operational factors such as workflow demands, organizational guidelines and user behavior, according to a BMJ release.
After reviewing the data, researchers found that 74 events related to safety problems with EMR technology, including false alarms, computer glitches and system failures. They also discovered problems with “hidden dependencies,” situation which a change in one part of the EMR system inadvertently changed important aspects in another part of the system.
The data also suggested that 25 other events were related to the unsafe use of technology, including mistakes in interpreting screens or human input errors.
All told, 70% of the investigations had found at least two reasons for each problem.
Commonly found safety issues included data transmission between different parts of the EMR system, problems related to software upgrades and EMR information display issues (the most commonly identified problem), iHealthBeat noted.
After digging into this data, researchers recommended that healthcare organizations should build “a robust infrastructure to monitor and learn from” EMRs, because EMR-related safety concerns have complicated social and technical origins. They stressed that this infrastructure is valuable not only for providers with newly installed EMRs, but also for those with EMRs said that in place for a while, as both convey significant safety concerns.
They concede, however, that building such an infrastructure could prove quite difficult at this time, with organizations struggling with meaningful use compliance and the transition from ICD-9 to ICD-10.
However, the takeaway from this is that providers probably need to put safety monitoring — for both human and technical factors — closer to the top of their list of concerns. It stands to reason that both newly-installed and mature EMR implementations should face points of failure such as those described in the study, and they should not be ignored. (In the meantime, here’s one research effort going on which might be worth exploring.)
When I began contemplating the subject of this blog earlier in the week, I thought I’d make room for thoughts on recent improvements in EMR adoption in the small practice and physician community, and the general state of optimism and enthusiasm some op-ed pieces would have us believe is finally taking hold of the industry. But then came along the potential delay of ICD-10, which also begs a quick comment or two.
A bill that included an effort to delay the ICD-10 compliance date a full year was passed, but only after partisan drama over the fact that legislators received the proposed bill just a day before the vote on it was to take place. I tend to turn to AHIMA on ICD-10 matters, and its official stance is fairly obvious:
Its reasoning is similar to that of the Coalition for ICD-10, which in a letter to the CMS, stated: “ … any further delay or deviation from the October 1, 2014, compliance date would be disruptive and costly for health care delivery innovation, payment reform, public health, and health care spending. By allowing for greater coding accuracy and specificity, ICD-10 is key to collecting the information needed to implement health care delivery innovations such as patient-centered medical homes and value-based purchasing.
“Moreover, any further delays in adoption of ICD-10 in the U.S. will make it difficult to track new and emerging public health threats. The transition to ICD-10 is time sensitive because of the urgent need to keep up with tracking, identifying, and analyzing new medical services and treatments available to patients. Continued reliance on the increasingly outdated and insufficient ICD-9 coding system is not an option when considering the risk to public health.”
AHIMA has even started a campaign to encourage its constituents to email their senators to urge them to also vote no when it comes to delaying ICD-10. At the time of this writing, the Senate vote is not yet scheduled. I don’t feel the need to restate my support of no further delay. You can read it here.
With regard to the other hot news items of the week, I was intrigued by the findings of the SK&A survey, which found that the EMR adoption rate for single physician practices grew 11.4%. One reason SK&A gave in the survey analysis was due to the “availability of more than 450 different solutions to fit their practice needs, size and budget.” Call me crazy, but I’m willing to bet that many solutions will not exist in the next three to five years thanks to market consolidation. What will these physicians do when their EMR vendor closes up shop? Time will tell, I suppose.
At least half a dozen folks have asked me to explain why HHS is mandating the transition to ICD-10. So I thought I’d write a blog post about the subject.
First, I’ll examine some of the benefits that proponents of ICD-10 site. Then, I’ll examine the cost of transition from ICD-9 to ICD-10.
There are about a dozen frequently cited reasons to switch from ICD-9 to ICD-10. But they can be summarized into three major categories:
1) The US needs to catch up to the rest of the world.
2) The more granular nature of ICD-10 will lend itself to data analysis of all forms – claims processing, population health, improved interoperability, clinical trials, research, etc.
3) ICD-9 doesn’t support the latest diagnoses and procedures, and ICD-10 does.
Regarding #1, who cares? Coding standards are intrinsically arbitrary. Sequels are not necessarily better than their predecessors.
Although #2 sounds nice, there are a lot of problems with the supposed “value” of more granular data in practice. Following the classic 80-20 rule of life (80% of value comes from 20% of activity), the majority of codes are rarely used. By increasing the number of codes six-fold, the system is creating 6x the opportunities to inaccurately code. There is no reason to believe that providers will more accurately code, but the chances of incorrect diagnosis are now significantly higher than they were before. Garbage in, garbage out.
Below are some specific examples of how increasing the number of codes will affect processes in the healthcare system:
Payers – payers argue that making codes more granular will improve efficiency in the reimbursement process by removing ambiguity. There is nothing further from the truth. Payers will use the new granularity to further discriminate against providers and reject claims for what will appear to be no reason. With 6x the number of codes, there are at least 6x as many opportunities for payers to reject claims.
Clinical trials – ICD-10 proponents like to argue that with more granular diagnosis codes, companies like ePatientFinder can more effectively find patients and match them to clinical trials. This notion is predicated on the ability of providers to enter the correct diagnosis codes into EMRs, which is a poor assumption. Further, it doesn’t actually address the fundamental challenges of clinical trials recruitment, namely provider education, patient education, and the fact that most patients aren’t limited to trials by diagnosis codes, but rather by other data points (such as number of years with a given disease and comorbidities).
Public health – ICD-10 proponents also claim that the new coding system will help public health officials make better decisions. Again, this is predicated on accuracy of data, which is a poor assumption. But the greater challenge is that the most pressing public health issues of our time simply don’t need any more granularity in diagnosis codes. Public health officials already know what the top 20 public health problems are. Adding 6x the number of codes will not help address public health issues.
Regarding #3, why do we need to reinvent the entire coding system and make the entire system more granular to accommodate new diagnoses and procedures? Why can’t we continue to use the existing structure and simply create new branches of the ICD tree using alphanumeric characters? Why do we need to complicate every existing diagnosis and procedure to support new diagnoses and treatments? We don’t. There are plenty of letters left to be utilized in ICD-9 to accommodate new discoveries in medicine.
Next, I’ll provide a very brief summary of the enormity of the cost associated with transitioning from ICD-9 to ICD-10. The root of the challenge is that a string of interconnected entities, none of whom want to work with one another or even see one another, must execute in sync for the months and years leading up to the transition. Below is a synopsis of how the stars must align:
EMR vendors – EMR vendors must upgrade their entire client base to ICD-10 compliant versions of their systems in the next couple of months to begin testing ICD-10 based claims. Given the timescales at which providers move, the burden of MU2 on vendors, and the upgrade cycles for EMR vendors, this is a daunting challenge.
Providers – providers don’t want to learn a new coding system, and don’t want to see 6 times the number of codes when they search for basic clinical terms. Companies such as IMO can mitigate a lot of this, but only a small percentage of providers use EMRs that have integrated with IMO.
Coding vendors – like EMR vendors, auto-coding vendors must upgrade their clients systems now to one that supports dual coding for ICD-9 and ICD-10. They must also incur significant costs to add in a host of new ICD-10 based rules and mappings.
Coders – coders must achieve dual certification in ICD-9 and ICD-10, and must double-code all claims during the transition period to ensure no hiccups when the final cut over takes place.
Clearinghouses – clearinghouses must upgrade their systems to support both ICD-9 and ICD-10 and all of the new rules behind ICD-10, and must process an artificially inflated number of claims because of the volume of double-coded claims coming from providers.
Payers – payers must upgrade their systems to receive both ICD-9 and ICD-10 claims, process both, and provide results to clearinghouses and providers about accuracy to help providers ensure that everyone will be ready for the cut over to ICD-10.
The paragraphs above do not describe even 10% of the complexity involved in the transition. Reality is far more nuanced and complicated. It’s clear from the above that the likelihood that all of the parties can upgrade their systems, train their staff, and double code claims is dubious. The system is simply too convoluted with too many intertwined but unaligned puzzle pieces to make such a dramatic transition by a fixed drop-dead date.
Lastly, switching to ICD-10 now seems a bit shortsighted in light of the changes going on in the US healthcare system today. ICD-10 is already a decade old, and in no way reflects what we’re learning as we transition from volume to value models of care. It will make sense to change coding schemes at some point, but only when it’s widely understood what the future of healthcare delivery in the US will look like. As of today, no one knows what healthcare delivery will look like in 10 years, let alone 20. Why should we incur the enormous costs of the ICD-10 transition when we know what we’re transitioning to was never designed to accommodate a future we’re heading towards?
At the end of the day, the biggest winners as a result of this transition are the consultants and vendors who’re supporting providers in making the transition. And the payers who can come up with more reasons not to pay claims. Some have claimed that HHS is doing this to reduce Medicare reimbursements to artificially lower costs. Although the incentives are aligned to encourage malicious behavior, I think it’s unlikely the feds are being malicious. There are far easier ways to save money than this painful transition.
The ICD-10 transition may be one of the largest and most complex IT coordination projects in the history of mankind. And it creates almost no value. If you can think of a larger transition in technology history that has destroyed more value than the ICD-9 to ICD-10 transition in the US, please leave a comment. I’m always curious to learn more.
I recently had a chance to sit down with Joseph Gurrieri, VP and COO of H.I.M. ON CALL to discuss two really important topics in the world of HIM: ICD-10 coder shortage and offshore medical coding. With the ICD-10 deadline for implementation breathing down our necks, many organizations are asking themselves where they’re going to get qualified ICD-10 coders. In the following videos, Joseph talks about the shortage and their approach to meeting the ICD-10 coding needs. After watching the videos below, I’d love to hear your thoughts on the subjects. Is there a shortage? Are you ok with offshore medical coding?
Shortage of ICD-10 Coders
Keys to Medical Coding Offshore
I don’t think it will be news to anyone reading this that HHS is getting hammered for their implementation of Healthcare.gov. Sebelius congressional testimony was brutal. Certainly the botched implementation of Healthcare.gov will have long lasting impacts on all future HHS IT projects.
While not purely an IT project, I wonder if the experience of Healthcare.gov will have an impact on the ICD-10 implementation. Will HHS be gun shy after the Healthcare.gov debacle that they’ll delay ICD-10 to avoid another one?
My gut reaction is that I don’t think this will happen, but it’s worthy of consideration.
On October 1, 2014, HHS’s IT isn’t ready to accept ICD-10, then you can read the headline already: “HHS Botches Another IT Project.” For those of us that work in healthcare IT, we know that ICD-10 has deep IT implications. Not the least of which will be CMS being ready to accept the ICD-10 codes. While you’d think this is a simple change, I assure you that it is not. Plus, if CMS isn’t ready for this, a lot of angry doctors and hospitals will emerge. It will be a major cash flow issue for them.
We still have almost a year for HHS to get this right. Plus, HHS has had years to plan for this change so they shouldn’t have any IT challenges. Although, if they do have IT challenges this extended time frame will damage them even more. The article will say they had plenty of time and they still couldn’t implement it properly.
With the comparison, there are also plenty of reasons why ICD-10 is very different than Healthcare.gov. In many ways, ICD-10 is a project implemented by companies outside of HHS as opposed to a project run by HHS. First, I think it’s unlikely that HHS won’t have their side ready for ICD-10. Second, their part of ICD-10 is very little compared to what has to be done by outside payers, hospitals, and doctors offices.
If ICD-10 has issues it will likely be seen as the payers or healthcare organizations not being ready as opposed to HHS. That’s not to say that HHS won’t have some damage if they force an ICD-10 mandate and people aren’t ready. They could have some collateral damage from it, but not the same as Healthcare.gov where the product is really their own product.
Plus, if ICD-10 goes bad, consumers/patients won’t know much difference. No patient cares if you code their visit in ICD-9 or ICD-10. They’ll still get the exact same care when they’re visiting the doctor. If ICD-10 goes bad, it will be doctors and hospitals that suffer. That’s a very different situation than Healthcare.gov which was to be used by millions of Americans.
I hope that HHS doesn’t delay ICD-10 based on their experience with Healthcare.gov. If HHS becomes gun shy about any project that IT touches, nothing will ever get done. That’s a terrible way for an organization to function.
I am finally decompressing from the AHIMA conference held earlier this week in my hometown of Atlanta. Conferences that last more than a day tend to leave me with great insight into the inner workings of healthcare and inspiration for several blog posts. An unfortunate side effect is the mountain of email and suggested industry reading that piles up. Another is feeling pulled in two different directions. As I lamented to several other attendees, it’s hard to dedicate yourself to early sessions and late networking events when you know the family is waiting for you at home.
Despite my inability to catch the early riser sessions, I spent a solid three days at AHIMA attending sessions, walking the show floor and catching up with colleagues in the press room. I came away with a greater understanding of the challenges providers (and vendors) are facing in the transition to ICD-10, as well as insight into how HIM professionals as a whole feel about embracing digital/mobile/connected health in a time (present and future) of heightened patient engagement.
1. Not only do coders need to know how to code in ICD-10, but they should also have more contextual knowledge of anatomy and procedures than ever before. Coding veteran Gerri Walk, Senior Coding Manager and AHIMA-Approved ICD-10 trainer at HRS, tells me that to be truly successful in ICD-10, coders can’t just memorize a book. They also must have extensive knowledge of anatomy and be really good at turning what a physician says into the correct code.
2. Coders are so overwhelmed with studying and training for the ICD-10 switch that they don’t have time to think about the bigger financial picture and coding-related consequences. Codes obviously affect reimbursement. The wrong code can lead to audits, appeals and lots of red tape that physicians – particularly those in smaller practices or smaller hospitals – can’t afford. I did not get the feeling that these kinds of consequences are being conveyed at ICD-10 bootcamps and training sessions, which is a pity. This is an assumption on my part, but it seems to me that coders might be more diligent in their coding if they had a real sense of the financial impact their codes have on their organization.
3. Experienced coders only, please. If you’re a recent graduate, you’re likely out of luck. Providers, like the women I spoke with at the Carilion Clinic, want coders with a lot of experience. They may ultimately shoot themselves in the foot, however, by not taking on newer coding professionals. Experienced coders will soon be harder to come by (some are retiring to avoid the ICD-10 transition). Providers might want to seriously consider hiring new grads and turning them into homegrown coding talent. Kayce Dover of recruitment firm HIM Connections tells me she is starting to see more and more of this.
4. Sorry coders, it’s not ALL about you. Physicians’ workflows will take a big hit when ICD-10 kicks into gear thanks to extra interruptions (er, communication) from coding staff. As Kerry Martin, CEO of VitalWare told me, coders will have to distinguish between what a physician says or writes about a procedure, and what a physician actually does during that procedure. (I get the feeling that coders may not be thrilled about having to second-guess physicians.)
5. Many coders are worried their jobs will be replaced by artificial intelligence and other technologies not even off the drawing board yet. Their worries are unfounded, according to Shiny George, Senior Director of HIM at Thomas Jefferson University Hospitals. She noted in her presentation on HIM in 2020 that their skill sets will still be needed, but will likely be used in different ways with new tools.
6. And speaking of new tools … the HIM profession seems ready and willing to embrace digital / connected health tools, as evidenced by their official endorsement of the Blue Button initiative. Consumer health and wellness apps were mentioned in nearly every session I attended. Patient and consumer engagement in healthcare via mobile devices is definitely on their radar, and they are well aware of the implications it will have on their profession. As George mentioned, HIM should not shy away from this trend, but should seek to embrace it, capturing and interpreting patient data in order to improve quality outcomes.
7. Gender equality is definitely a priority for female HIM professionals when it comes to achieving leadership positions. I attended several sessions on this topic, and will offer insight specific to this takeaway in next week’s post.
My prediction that the AHIMA Convention would be all ICD-10 all the time was generally true. ICD-10 is on the mind of everyone at the conference. Although, I did hear one attendee that was really happy to find someone that could talk EHR data conversion. They also predicted that next year there would be the year of EHR data conversion. We’ll see how that plays out. I still think next year might be a lot of people complaining about ICD-10.
I’m always impressed by the people I meet at AHIMA. They’re a wonderful group of people that are devoted to the cause of healthcare. These people have some pretty tough and often mundane jobs that often don’t get paid very well, but they do it with such class and dignity. It’s always a pleasure to be around such an amazing group of people.
I’m definitely inspired to do a weekly series of ICD-10 blog posts. I’ll look at starting that next week. Hopefully we can bring out of denial some of the people that aren’t focused on the impacts that ICD-10 can have on their organization. Not to mention the training needs that many have for ICD-10.
I’ve also shot a number of great videos with people I’ve met at AHIMA. They’re short and sweet and hit on a specific subject. I think they impart some good wisdom. Be sure to subscribe to the Healthcare Scene YouTube channel to get the latest video uploads. Plus, we’ll be posting them across the Healthcare Scene network over time.
Are you ready for ICD-10? Are there ICD-10 topics you’d like to see covered in the future? I’d love to hear your thoughts about it in the comments.
We’ve been writing about the coming ICD-10 deadline for a while including when the ICD-10 deadline was delayed another year. Every sign I’ve seen says that ICD-10 won’t be delayed anymore. The rumblings are starting to come out that many healthcare organizations aren’t ready for ICD-10.
In response, to this, I found it interesting that the TrustHCS Academy has put together a program to train coding professionals on ICD-10. I expect many medical coding professionals will be interested in this type of class. ICD-10 is one thing that could really benefit from a training class like this.
I recently was part of a discussion where an Epic EHR consultant was saying that EHR had been mandated and everyone should get on board or else suffer the consequences. I quickly corrected him that there is no EHR mandate. In a rare moment, he apologized for his mistake and agreed there was no EHR mandate. Then, he asked an interesting question, “Is ICD-10 a mandate?”
I guess in its purest form, ICD-10 is not a mandate. If you’re ok practicing medicine with only cash pay payments, then I guess you could choose not to use ICD-10. However, if you want to get reimbursed, then ICD-10 has been mandated.