Q&A: Rethinking ICD-10 and electronic health records
ICD-10 and electronic health records are most frequently considered separate projects, undertaken by separate teams – but perhaps they ought not be.
Government Health IT spoke with Heather Haugen, vice president of research at the Breakaway Group, a Xerox subsidiary, about opportunities the ICD-10 delay opens up in terms of clinical documentation and alignment with EHRs, controlling coders' learning curve, the anticipated productivity loss following the compliance deadline and why healthcare entities are waiting on their tech vendors to get the conversion underway.
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Q: How did the delay come about, anyway? I have to think there was a lot more involved than a pair of open letters the AMA sent to HHS Secretary Kathleen Sebelius and House Speaker John Boehner.
A: Like all things, I think it was political. I do think, though, that when HIPAA 5010, so few people were prepared and there were so many issues, that it brought it to people's attention that, "Wow, this is a small piece of this. Imagine what will happen when we move to the next piece." And so I think that opened people's eyes to the complexity of this and that they have to be serious about it.
And I think the AMA had a pretty strong impact on what was going on, representing physician practices, although there are all kinds of rumors about why and how. Interestingly, I think many people found the delay to be most troubling because they didn't know when the new date was. So I'm very happy that we have a date, a target, so for people who are good stewards of the process and were working on that it helps them. And in healthcare we have enough stresses that we don't need to add anymore.
Q: Speaking of stresses, one aspect of the ICD-10 conversion that has drawn a lot of attention is the anticipated loss of coder productivity in the time after the compliance deadline. Given the extra year, what can providers do to avoid that?
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A: Some of the things people are doing now. Coders need to learn more anatomy, more physiology, more of those kinds of things in order to prepare for this. But my strong opinion is that the coder is going to be on the receiving end of poor documentation. So we talk about how we are going to start with good documentation, which is going to help the coder. What if I gave the opportunity to practice using ICD-10 for a month? You'd get really good at it. So practice. And it's easier to get coders to do that work than it is to get physicians. They know their world's about to change and it makes them very nervous.
There's another concept from the learning literature called "fail-fast." There's no better way to learn than to fail, very quickly, and to get immediate feedback. Now, we don't want them to do that during the first month in the ICD-10 system – that would be a nightmare. If we allow them an environment where they can fail fast, they actually learn very quickly. Having this additional year, we need to be spending our time giving those coders some time, which is hard to come by in healthcare, to learn the system. But it would pay off in that first months if we have a nice cadence of working rather than being behind the eight ball, making mistakes, missing bills.
Q: Following that, another issue we hear a lot about with ICD-10 is the need for better documentation. Particular to clinical documentation, what are the big opportunities that ICD-10 presents?
A: One of the things that was shocking to me, and maybe shouldn't have been, was this real focus on, "This is a mandate and we're just going to have to do it." I think when you say that to clinicians, their brain turns off – and kind of for good reason. It's something that they have to do and they're not really signed on for. So one of the things we've been working hard on is determining how to understand what clinicians are trying to accomplish, and help align some of their interests with what we need to do around ICD-10. To understand, from a research perspective, that the benefits we get from better understanding the specificity of disease, there's some real value around public surveillance, and how we report in our individual healthcare organizations, about the types of diseases and conditions that we're treating.
The thing I found so fascinating about this move to ICD-10, and eventually ICD-11, which brings SNOMED with it, is the concept of aligning this with our efforts to adopt electronic medical records and our ability to really understand how to use decision support to improve quality of care. And I do think by being more specific, there's a nice play back and forth with clinical decision support and we can learn some things about how we're treating patients and maybe more importantly how we can apply evidence-based medicine to these diseases. And the reporting of that, and the ability to have more data about those pieces is really important and not something clinicians just sing-up for. That's something to which clinicians go, "A-ha, you have my attention. I understand where there might be some long-term value in this and, therefore, I'm going to commit to doing a better job of documenting."
Q: What should providers be doing today to start down that road?
A: We actually could be documenting at the level we need for ICD-10 right now, today.
Q: Doing that in ICD-9, you mean?
A: Exactly. It doesn't matter what the final code is. If we're documenting with better specificity that doesn't affect the coders. In some ways it helps to give them the level of specificity they need eventually to code in ICD-10. Another thing I think we need to do as ICD leaders is help narrow the code sets for coders and help narrow how we're using electronic medical records to give them fewer choices, fewer things to pick from, and I think there's work that can be done on the technology side to facilitate that learning. Helping clinicians understand, especially in their areas of specialty, what that documentation looks like, and then going back and observing, coaching and giving feedback to improve that process, is something we can start today.
Q: You mentioned aligning ICD-10, and beyond that ICD-11, with EMRs and related initiatives. How can health entities actually start down that road?
A: Part of it is we think of these things as separate projects and they're not really projects. They're ongoing efforts so we have a group of people working on EMR, and a group of people working on ICD-10, so even strategically, where there's overlap the folks involved in both need to understand what the goals are for where we're trying to get. If we can ensure that we're truly adopting, and using the electronic medical record, and the clinical decision support and CPOE, then we can use some of the reporting to come from ICD-10 within our EMR systems.
Ensuring that in the EMR we're only giving clinicians the information they need in those cases will help them. As I was talking to some of the folks that work in the standards world, and others, they were saying there's no reason why we should be presenting clinicians with these enormous code sets. Instead, we should be doing a better job giving them the information they need at the time they need it – and that's even on the EMR vendor side.
Q: At one point in time, maybe about 18 months ago, payers were seen to be leading the charge, then they found the conversion more costly and resource-intensive than expected, and downshifted accordingly. Where do things stand today – are either payers or providers ahead?
A: Interestingly, healthcare organizations are ahead of the vendors, who are trying to catch up and make their software compatible with ICD-10. The reason, I think, is because I'm talking to several healthcare organizations that are actually waiting for the vendor to be ready before doing some of the work they have to do. Now, I've also talked to a couple vendors who say the same thing, that healthcare organizations are literally waiting for them.
Q: And they're waiting on vendors for systems remediation to the seven-digit fields?
A: Yes. Plus, I think some of the vendors were hoping to provide tools and information around improving documentation to make some of this easier. Not just complying but, say, using their EMR tool as a way to have competitive advantage around what they're presenting and how they're capturing documentation under ICD-10 so that it really does help the clinician.
[See also: Could the U.S. skip ICD-10 and leapfrog directly to ICD-11?]
