DISCLOSURE:
Reminder that I am a practicing physician, hospital/health system
administrator, and also the Chief Medical Officer of a CDI/ICD-10 vendor
called ICDLogic.
Want to thank all of you for waiting so patiently for this follow up post to National Countdown to ICD-10: A Status Report.
Co-author: Brian Hannah, MD, MS, CPHIMS, CMIO, Mercy Health System, Conshocken, PA
Introduction
As previously stated, despite heavy preparation and recent developments/concessions from regulators, I continue to have significant concerns about the upcoming transition to ICD-10. My concern is primarily for the independent practitioner (of which I am one) and the already decreasing number of small private practices in the US- approximately 60% of our nations doctors. I'm concerned about the impact of I10 on the routine workflow of doctors and is well-documented in my previous post, this post will focus on a potential solution.
This solution is not my idea, is not new, and is definitely not easy, but it is something that I believe is absolutely necessary for our great Nation to have the highest level of success with the I10 transition. In brief, it definitively shifts the language of clinical coding from one standard to another. Namely, ICD-10 to SNOMED-CT.
Overview
When Mr. Smith gets admitted to the hospital with a severe case of asthma, his doctors and nurses create documentation of his visit. This documentation is written in clinical language that each provider has learned through their training. Though there are small variations in the style of documentation, the quality of documentation is most often dependent on the provider's level of experience. It generally takes 3-5 years for most providers to learn their communities conventions but most would not argue that there is only small variation between communities of providers. This means that the description of asthma in Boston is pretty much the same in Florida or New Mexico.
Mr. Smith's asthma is documented in clinical language- nurses, doctors, payers, and many other officials use this documentation throughout his visit and afterwards. Upon discharge, his chart is whisked away to the Hospital Information Management Department (aka Medical Records) where an entire world of other people begin reviewing the case and initiate/continue the process of medical coding. Just like we are communicating in English right now, this medical coding is currently done in the ICD-9 code set. The coders read the chart and take literal documentation and convert it into codes, ie. the words describing his asthmatic attack (status asthmaticus) would be converted into 493.21. In ICD-10, depending on a bunch of other things (previously outlined), it might code to J44.0. Whether you use 493.21 or J44.0, most physicians (including me) will say, "What the heck are you talking about!?!??" You see, only payers and regulators "care" about this... well, I guess all the reform has also now engaged the patient... rats, I hate when Obamacare comes out on top!!
This process is fine and good in the hospital because we generally have the resources to provision an adequate number of qualified medical coders to abstract this data, but it is quite different in the private setting. It is my opinion that our payers have very noble intention's to shift the responsibility of coding to physicians so that various issues (including errors of omission) in the abstraction process are minimized/eliminated- ICD-10 can do a fairly good job of that, but at significant expense to the provider (as previously documented). I'm sure it has nothing to do with the fact that coders are "middle-men" in this process and would like to be paid for their service; after all, we all know how generous our Payers are...
The Issue
There are approximately 18,000 ICD-9 codes- this may sound like a lot, but it is actually not that many if you consider there are dozens of medical specialties that carve out some subset of this number. So even if there were only 40 subspecialties, we're looking at approximately 500 codes per specialty- give or take... Most docs have memorized at least 500 or so obscure facts in their first semester of medical school. Even still, computer-based systems were probably not as good as a good pocket card or "Superbill" (which is just a big pocket card) that listed the most common diagnoses. The problem is that we're now going from 15 to 50 to hundreds of codes per diagnosis. To be more precise, from 13,000 ICD-9 CM codes to 68,000 ICD-10 CM codes and 4,000 ICD-9 PCS codes to 83,000 ICD-10 PCS codes- that's from 17,000 to 151,000 codes!!! Using our previous calculations, even our brainiest docs will take quite a bit of time memorizing 4000 new codes... but the real question is, do we really want them too??
The Solution
So what if they didn't memorize codes?? What if they documented in SNOMED CT? Like Spanish, SNOMED CT is just another language (for all you technogeek Informaticists, it's a Terminology). The difference though is that doctors already KNOW SNOMED CT!! It was developed from the very same textbooks that we all studied throughout our training. It is the language that we are already speaking, reading, and writing in... it doesn't need to be abstracted by coders, it IS the code in and of itself. It is the preferred way to INPUT data, it is not so good at REPORTING data, that is ICD-10's strength (hey technogeeks, it's a Classification). In other words, SNOMED CT is great for inputting data where ICD-10 is great for reporting outcomes.
SNOMED CT has over 300,000 terms that can be combined in nearly unlimited permutations. Though this may sound daunting to us humans, computers eat that kind of thing up!! However, computer systems with this capability are non-existent and though I'm sure there are people working on this problem, some of our brightest programmers are working on the next knock off of Angry Birds (personally I'm a Plants vs Zombies guy myself...)
The good news is that Meaningful Use criteria are essentially requiring the use of SNOMED CT for certain documentation. The bad news is that there is no "lobby" or special group out there that is powerful enough to convince Payers and regulators that they should invest in helping EHRs and other vendors to produce systems that can convert SNOMED CT into ICD-xx, LOINC, and other code sets of tomorrow. EHRs are particularly woeful in giving clinicians tools to document in ICD-10 in the first place, so can essentially "bail-out" a lot of EHRs from having to invest in this activity.
The Proposal
So now that you know all of the above, let's do this:
- Make CMS adopt SNOMED CT as the de facto standard for clinical documentation (it kind of is anyway)
- Identify funding for EHRs and vendors to produce SNOMED CT to ICD-10 conversion systems
- Continue to push Meaningful Use incentives
- Live happily ever after...
If you think this is a reasonable proposal, please sign our petition with your support (no purchase required!!):
Discussion
Clinicians and payers can both be satisfied by this proposal, but how often is there REALLY a WIN-WIN in healthcare administration? Experienced professionals might say rarely and I would have to agree...
The real truth is that there is a third party in this story that is often under-recognized. That is our friendly-neighborhood HIM professionals. Unfortunately, just like the rest of us, this party has a silo of their own
and might be quite content with things as they are- you see,
coders generally work in the HIM department, and they are just as averse to change as the next guy. Any changes to this
portion of the revenue cycle will mean retraining for all of these
colleagues...
So at the end of the day, if this proposal is successful, payers will be none-the-wiser (they get ICD-9/10), incentivize clinicians to document in SNOMED CT (which they are doing anyway), create jobs (and profits) for EHRs and vendors (after all, we don't want them to starve), and put a bunch of coders out of business (they are already used to starving).
The hope is that patients will somehow benefit from all of this... Maybe I'm a little biased, but as a patient, I really want my doctor to at least FEEL supported! If nothing else, this proposal can at least do that. All in a days work when it comes to clinical transformation.
Glossary
CMS- Center of Medicare (and Medicaid) Services
EHR- Electronic Health Record
HIM- Health Information Management
ICD-9- International Classification of Disease version 9
ICD-10- International Classification of Disease version 10
LOINC- Logical Observation Identifiers Names and Codes
SNOMED CT- Systematized Nomenclature of Medicine Clinical Terms
DISCLOSURE: Reminder that I am a practicing physician, hospital/health system administrator, and also the Chief Medical Officer of a CDI/ICD-10 vendor called ICDLogic.
Introduction
Now that the Sustainable Growth Rate (SGR) Bill has been repealed by congress and is expected to be rubber stamped by Senate and President Obama, it is with mixed feelings with which I write about the status of ICD-10 in our nation. As the US healthcare system scrambles in these last few months to prepare for the transition, my feelings as a vendor are self-explanatory. My roles at my hospital and health system brings feelings of vindication as all our preparatory work will not go wayside again. As a
data junkie, the more data I have, the more information I can create.
So, as long as the entered data is valid and ACCURATE, the analytic part
of me is excited about the opportunities that ICD-10 will bring.
Researchers, most healthcare vendors, and payers are of the same mind-set. Needless to say, so is the Center for Medicare Services (CMS). The hope by all is that
more specific documentation will give us the data we need to help us manage and improve the care our providers deliver to our patients.
However, as a practicing physician I am fearful. Not so much for my own practice but for all my physician brethren (and sistren of course). This post outlines my fear and briefly presents my concerns. As with any blog, these are my opinions and I don't consider myself an expert. I would be greatly appreciative if anyone tried to allay my fears- please comment below.
Who cares? What's the big deal?
CMS has advised that all healthcare organizations have THREE months revenue
on hand in preparation for ICD-10 transition... With the average
solo-practitioner having maybe $30k per month in revenue, I would bet
that the majority do NOT have $100k in their rainy day fund. Delays in
payment to these providers can be catastrophic to their communities and
will redirect patients to others. Many of which are already
booked solid for months on end. Finally, the "nice guys" that accommodate are doing so by
reducing their availability to their existing patients- namely you and
me. The point of this is that we're all in this together.
How will ICD-10 change practice?
Asthma is a fairly straightforward clinical disease to diagnose and treat. Coding in ICD-9, however is a different story but one that most providers become very proficient at after some practical experience. There are essentially five ICD-9 codes for asthma, each having 3 subtypes gives a total of roughly 15 codes to choose from. Description of asthma in ICD-10 has over 50 options and will require additional specification to meet reimbursement criteria, namely one of the following:
- Exposure to environmental tobacco smoke (Z77.22)
- Exposure to tobacco smoke in the perinatal period (P96.81)
- History of tobacco use (Z87.891)
- Occupational exposure to environmental tobacco smoke (Z57.31)
- Tobacco dependence (F17)
- Tobacco use (Z72.0)
Also worthy of mention is that the language of ICD-10 is a coding language, that is, suited for medical coders, not so much for typical clinical staff, especially doctors who speak essentially a different language and need to learn the codes. This and the sheer volume of options will require much more thought from the provider to first document, then select the correct diagnosis (and code) even though the treatment and management of any subset of them varies little (if at all). More intimidating is that the additional criteria are not "related" to asthma in that providers don't have an easy way to know or be reminded that these criteria MUST be specified. In the ICD-9 world, paper job-aids are often littered all over the office reminding providers and staff to document the right information. However, in ICD-10 the volume of new documentation will require electronic systems to support this activity. Time (and cost) spent on these systems is time spent away from you and I as patients! In a world where the amount of time spent at the bedside continues to plummet, this adds insult to injury. These issues can not be under-emphasized and will sincerely debilitate medical practices that do not prepare in advance for them.
My Concern
If we don't comply with the mandate, we will not be paid! No ifs, ands, or buts, NO BUSINESS, HOSPITAL, or MEDICAL PRACTICE CAN SUSTAIN NON-PAYMENT!!
I worry least about Hospital-based providers that are a part of a large health system as they have tremendous resources to help prepare their providers. Independent hospital-based providers will also be OK as they too have help. It is the independent providers and group practices that I'm concerned about most, currently about 60% of our healthcare system! As one of them, we don't have any help!! More importantly, we don't have any one TELLING us we NEED help!! This is very alarming to me and is the basis for my authoring of this post.
The issue of awareness is more complex than it sounds. Yes, the aware providers who understand the effect of the
transition are seeking out assistance as we speak, but what about those that are not aware? Well, leaders like myself are paid to reach out to them one by one offering assistance. But there is a significant chunk of providers that either cannot be reached and/or go out of their way NOT to be reached. It's very possible that your doctor may be one of these people. And if they are still documenting on paper, they will have tremendous difficulty preparing, even after they become aware. With five months remaining, these people are in deep trouble, and they don't even know it.
What about Technology?
Fortunately, there are tools, including ICDLogic's Cypher, which are fabulous in supporting aforementioned colleagues that are trying to stick with the program. There is also ComplyMD and Provation and 3M and a number of other emerging vendors, each with their own strengths and weaknesses. The astute reader will notice I did NOT include the major EHR vendors here... bringing me to my final fear about the impending ICD-10 transition date.
Most of the major electronic health record (EHR) vendors have completely missed the boat here. Up until recently, when the average CMIO reached out to the average EHR-vendor, the average response is "you're covered by IMO". Intelligent Medical Objects is a prominent terminology vendor that the majority of hospitals that have EHRs already subscribe to. But the truth is that IMO is far from a comprehensive solution as it only "powers" the functionality that is inherent in the EHR itself. This is not completely the truth as some EHR vendors are more thoughtful than others, but I have yet to find a solution that is anticipated to be bump-free. And I have seen multiple vendors make promises that they are far from delivering on in April 2015.
Given the asthma example above, it should be easy to see that what was previously a list of 15 choices will now be a list of 50 choices for asthma, hundreds of choices for other more common conditions like diabetes, and THOUSANDS of choices for procedures like knee replacement or cardiac catheterization- when's the last time you scrolled to the SECOND page of a Google search result let alone the 15th? Even you are willing, this approach is WITHOUT any mention or guidance of the "additional" diagnoses that most payers will require to consider the documentation complete.
The Solution
SNOMED CT- see my next blog post for more details
Conclusion
As we are all patients, those of us that love and appreciate our doctors and want them to be around after ICD-10 becomes official should inquire with them about their preparatory plans. Aside from showing empathy liberally, actively inquiring is the best way for patients (and administrators) to support our providers. Direct them to local experts and ask them to check in with their billing colleagues to make sure they are "dual coding" in preparation for the transition date. Although it is a costly exercise, this is one of the most effective things any practice can do to prepare.
As for me, in addition to the carefully devised, systematic approach I am taking on behalf of the various stakeholders I serve in my other roles, I will also cross my fingers and hold on to my lucky rabbits foot while making a special prayer in the name of the US Healthcare System. No level of support is too little for us to be prepared for what is currently still considered the ominous date of October 1, 2015.
Take a 2 minute and 25 second break to watch this video:
Patients want physicians in practice to be passionate about the care they deliver. This passion can be expressed in a multitude of ways including the time we spend at the bedside as well as in the care we take in meticulously reconciling the medical record. Whether we agree with it or not, our documentation of care is in part an artistic expression. It seems there is much pressure to "Standardize" documentation and many argue that would be analogous to saying only water-colors can be used to create art. I submit to you that standardization does not need to have any impact on the artistic expression of our care.
I will never forget the day during my residency when on rounds a well-respected Critical Care attending faculty member was annoyingly flipping through the chart and stopped at my note and said, "Finally, a note that will tell me what's going on with this guy!" Aside from being one of the greatest moments of my professional life, this seemingly minor event showcases the importance of good documentation on care delivery. It also suggests that there is often an emotional response when our documentation is the topic of discussion. Understandably so as our professional reputation and ultimately our entire livelihood is built upon these notes.
One of the main criticisms of electronic documentation is the advent of the Structured Field. Even my 9 year old will agree that "The patient has right-sided chest pain exacerbated by palpation and deep breathing with associated shortness of breath" is more meaningful than: "Location: R, SOB: Y, Chest Pain: Y, Other: pleuritic, exac. by palpation". Even though natural language processing is slowly bridging this gap, it is imperative that we preserve this age-old notation, otherwise known as narrative or prose, and use technology whenever appropriate/possible to meet emerging demands/standards.
These tenants of documentation are fundamental to the process of clinical evaluation and though the electronic record might seem to lead us astray from established practices, it remains up to us to choose the frame and the matte for our Art.
