Chuck Podesta is Fletcher Allen Health Care’s chief information officer.

ICD-10 would not be so daunting if the deadline was not occurring during the rush to get EHRs for meaningful use. Add in value-based purchasing, bundled payments and transitioning to ACOs, and you can see why many CIOs are retiring early or migrating to the vendor or consulting world. We are just over two years away from the October 2013 deadline, and there is much work to be done. ICD-10 contains 68,000 codes, as opposed to the 13,000 currently used in the ICD-9 world. There is a code for every condition that exists on the planet.

The revenue cycle system, which includes registration, HIM and billing/AR, will be the lynch pin to ICD-10 readiness. Having a solid vendor partner and a strong product is key to a successful transition. Many solution providers – like GE Healthcare, who recently launched the 5.0 version of their Centricity Business product – are updating their systems to better comply with ICD-10. GE Healthcare also allows existing Centricity Business customers to retrofit the new ICD-10 functions to the 4.6 version of the product. Strong vendor partners take the burden off you by being ahead of the game and delivering the appropriate technology in time so you are not racing to the finish line.

By now, you should have at least a steering committee in place. Your IT shop should have completed an inventory of all applications that are impacted by ICD-10, including reporting systems. You will be surprised by the number of applications, even if you have taken the one-vendor approach for most of your IT needs. You will need to contact all affected application vendors to see what the plans are for ICD-10 compliance. Most likely, upgrades will be required that will need to be scheduled.

Training of coders will be critical, along with implementing clinical documentation improvement programs. Documentation improvement programs are difficult to implement and will be viewed by providers as more work on top of an already busy schedule. New technologies such as computer-assisted coding will definitely help, but success will be a combination of process improvements and technology.

Lastly, remember that the deadline is for Medicare and Medicaid patients only. Unless the rest of the payer industry follows the same deadline (highly unlikely), you will need to run both ICD-9 and ICD-10 systems.

Probably unintentionally, it seems like various HHS branches are playing good cop-bad cop right now.

I’m in Ojai, Calif., right now (please don’t hate me because of it) for the annual Association of Medical Directors of Information Systems (AMDIS) Physician-Computer Connection meeting, a gathering of chief medical information officers and others in the field of what AMDIS likes to call applied medical informatics. That contrasts with the American Medical Informatics Association (AMIA), which tends to draw more from the academic side.

The Office of the National Coordinator for Health Information Technology (ONC) apparently is the good cop. National health IT coordinator Dr. Farzad Mostashari was unable to make it out here from Washington, but he addressed the gathering by telephone. Unfortunately, he called into a cell phone hooked up to the PA system in a room already suffering from poor cellular coverage, so some of his words were clipped. But a few things were clear.

Mostashari indicated that he was in favor of delaying the start of Stage 2 of “meaningful use” to 2014, even for those who meet Stage 1 requirements this year. That’s the recommendation that the Health IT Policy Committee made to him a couple of weeks ago. Furthermore, if CMS approves the delay—CMS is producing and administering the EMR incentive program—Mostashari said that providers will be able to earn three years of Medicare and/or Medicaid bonus payments, not just two years’ worth, prior to the start of Stage 2.

That, not surprisingly, elicited some smiles and nodding from attendees. Mostashari, himself a medical informatics veteran with a primary care and public-health slant, played to the crowd by pointing out how health IT is accelerating real reform of American healthcare—not just an expansion of insurance coverage that to me is just throwing more money at a broken system. “We’re moving away from the fee-for-service model comfortably faster than we had anticipated,” he said.

Meanwhile, CMS came off looking like the bad guy, at least in contrast to ONC.

The agency already is taking a lot of heat from many parts of the healthcare world, which has heaped tons of criticism on the proposed Accountable Care Organizations rule. Just after Mostashari’s session, Ethan Moore, a health IT and HITECH Act specialist at CMS, hosted an update on the Medicare and Medicaid agency’s efforts in health IT, which included two other CMS technical specialists calling in on the phone.

One of the callers delivered a disheartening message to the 200 or so informaticists present: the Oct. 1, 2013, deadline to convert to ICD-10 coding is “firm.” That may not have surprised anyone, but it certainly seemed disappointing, given that there’s probably going to be more time available to achieve later stages of meaningful use.

Moore also showed slides that walked through the online application for attesting to meaningful use. Moore was an engaging speaker, albeit not as enthusiastic as Mostashari, but a lot of eyes still glazed over. Blame it either on the relatively early hour if you want, but I think it had more to do with the bureaucratic nature of the process. I suppose there isn’t much anyone can do about that. If there is, I’d love to know exactly what.

Two articles I’ve written in the last 24 hours have gotten me thinking that we’ve already entered the post-implementation era of EMRs, even as implementation remains in progress at so many healthcare organizations. While the vast majority of hospitals and physician practices in the U.S. still don’t have full-featured EMRs in place, many are already looking well into the future.

As you may already know, HIMSS on Tuesday released its first-ever survey on “clinical transformation.” According to HIMSS and survey sponsor McKesson, “Clinical transformation involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and IT implementation. By effectively blending people, processes and technology, clinical transformation occurs across facilities, departments and clinical fields of expertise”

As I reported for InformationWeek, 86 percent of organizations surveyed had a plan for clinical transformation in place or at least under development, and just 12 percent of respondents called organizational commitment a barrier to reporting on quality measures. And though nearly 8o percent indicated that they still gather quality data by hand and 60 said they don’t capture data in discrete format, more than half already had software specifically for business intelligence. This tells me that analytics is here to stay.

I kind of knew that anyway, since the bulk of the program at last week’s Wisconsin Technology Network Digital Healthcare Conference was devoted to BI, data governance and advanced analytics tools, even in the context of Accountable Care Organizations. (My story about this for WTN News appeared this morning.)

“I’m ready to declare the era of business intelligence,” said Galen Metz, CIO and IS director for Madison-based Group Health Cooperative of South Central Wisconsin. Though he criticized the proposed ACO rules for being too “daunting” for the average provider, Galen and other speakers said that it’s time to harness all the new, granular data being generated by EMRs and, soon, ICD-10 coding.

It may seem “daunting” now in the midst of all the preparations for ICD-10 and meaningful use, but it’s good to know that many healthcare organizations see a light at the end of the tunnel and know that the future bring better healthcare information in exchange for all the hard work and investment today.

I guess kind of like they just had Shark Week on TV, this week on EMR and HIPAA has been ICD-10 week. So far I’ve covered EMR vendors ICD-10 planning, moving to ICD-10 and bridging from ICD-9 to ICD-10.

In response to my previous ICD-10 posts, Gordon Fenton provided this interesting insight about the UK’s experience with ICD-10.

Over in the UK we already use the ICD10 along side the OPCS code to generate our HRG’s which is the currenvy that commissioners and providers use in the billing process.

While I am based on the commissioner side I know that our providers employ coders whose specific job is to translate Doctors notes into ICD and OPCS codes.

The main challenge will be in varifying and validating the codes being applied by providers, the IT is just a small issue. It will be very easy for providers to inadvertantly apply the wrong code simply by the fact that there are so many.

You could do a lot worse than look at the UK model for guidance on how we deal with it

I’m always interested to learn from what other countries are doing with technology and EMR. I’d love to learn more about UK provider’s experience with ICD-10 and how we can improve the eventual ICD-10 implementations in the US.

In response to my previous EMR and ICD-10 posts, an EMR vendor recently sent me how they plan to address the transition from ICD-9 to ICD-10. Here’s their plan:

1. We are going to have both the ICD-9 and ICD-10 codes reside in the same file in our application. This will allow the charge entry people to enter either code. There will be a field in the ICD-9 that will map to a single ICD-10.
2. We will provide a report to each doctor showing them the frequency of the ICD-9 codes they used over a period of time that they can specify. This report will show the available ICD-10 codes. The doctor can study it, start to change, or ignore it.
3. The staff can opt to let the software map one ICD-10 to the ICD-9 or manually enter the code of their choice.
4. Our electronic claims software will have a flag per insurance carrier indicating whether or not it will accept ICD-10. For those that will, we will map the ICD-9 to the 10 and send that code. If no map identified, we will generate an error edit.
5. At some point down the road, we will use the information collected from billing to update the doctor’s preferred list of dx codes in the EMR.
6. We will have to augment customized programs at each client site that may be doing reports based on ICD-9.

The push to ICD-10 is rapidly approaching. That’s why I was interested to know how EMR vendors were going to get the ICD-10 code list. However, there are going to be a lot of other nuances for EMR vendors to move from ICD-9 to ICD-10.

The following is a short description of some real data around the move from ICD-9 to ICD-10. It’s from a newsletter sent out by ArcSys including some interesting data from a real clinic. It’s going to be interesting to make the transition to ICD-10 along with all the fun things happening around Meaningful Use.

On October 1, 2013, all claims processing needs to be transitioned to the new ICD-10. As you can well anticipate, this will be a major change for the healthcare industry. As a practice, your biggest challenge will be the re-education of the staff on what the new codes are and their associated nuances. Starting January 1, 2011, CMS will start to accept the 5010 claim definition which will allow for the transmission of the ICD-10 codes.

ArcSys will have the software tools in place to assist you in the transition. We can provide you with reports showing the frequency of which ICD-9 codes have been used by each provider. The major problem is that there is no one-to-one mapping—it is one-to-many for numerous codes.

As an example, from an internal medicine group, the number of times that a diagnosis related to diabetes over a one-year period produced the following part of a report:

250.00 703
250.01 81
250.02 145
250.03 27
250.30 1
250.40 16
250.43 2
250.51 1
250.60 43

If you look at the published mapping files as provided from the Centers for Medicare and Medicaid Services, you will find the following “simple” example:

25000 E119 10000
25001 E109 10000
25002 E119 10000
25003 E109 10000
25010 E1310 10000
25011 E1010 10000
25011 E1011 10000
25012 E1169 10000
25013 E1010 10000
25020 E1101 10000
25020 E1100 10000

Thus, ICD-9 code 250.00 maps to E11.9 (Type 2 diabetes mellitus without complications), and 250.20 maps to either E11.01 (type 2 diabetes mellitus with hyperosmolarity with coma) or E11.00 (type 2 diabetes mellitus with hyperosmolarity without nonkeototic hyperglycemic-hyperosmolar coma). Clearly, some “dusting off” of the old textbooks may be necessary to get a better understanding which code might make the most sense. (The 10000 number is a “computer number” that will be used to identify the degree of association between the the ICD-9 and ICD-10. It is far too-complex to describe in the space allotted here.)

I remember when I first started my job at a healthcare facility 5+ years ago, I ran into these codes they called ICD-9. Yes, this was all very foreign to me, but I learned quickly the meaning of ICD-9. I also learned quickly that the EMR vendor which had been selected (before I was there) didn’t provide a list of ICD-9 as part of their EMR software (they do now). They did provide an upload feature and so we exported a list out of our old PMS, cleaned them up a little and then uploaded them into the new EMR. Not a fun or effective process even that way.

Obviously, we’ve come a long way in five years. There are plenty of free lists of ICD-9 codes around the net that people can use, manipulate and add to their EMR software pretty easily.

However, I couldn’t help but wonder what solutions were being offered for EMR vendors planning for ICD-10. Yes, EMR vendors do have until October 1st, 2013 (which has been moved back a bunch of times so let me know if it’s been changed again) and so maybe EMR vendors aren’t concerned about it yet. Although, I’m guessing that many have already put a lot of thought into preparing for ICD-10.

My question for EMR vendors is, how are you planning to handle the ICD-10 codes? We’re talking about going from 14,315 diagnosis codes to 69,101 diagnosis codes. The National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS), AHIMA, the American Hospital Association, and 3M Health Information Systems have put together some General Equivalence Mappings (GEMs) that I believe try to do some mapping between ICD-9 and ICD-10. However, like translating a language there’s rarely a one to one match. With 4+ times as many codes there couldn’t be. So, certainly there’s the question of how you’re going to make the transition from ICD-9 to ICD-10 coding?

Although, at a simpler level, how are you planning to get the almost 70k ICD-10 codes in your system? Does anyone know of a database of these codes that’s available for EMR vendors? Is each EMR vendor going to try and create their own? What’s happening in this regard?

And maybe the answer is….ask us once we’re done dealing with stage 1 meaningful use. ICD-10 isn’t until stage 2 or stage 3 meaningful use.

One of the really interesting conversations I had recently was with Tori Sullivan from Capgemini. Tori is knee deep in the fun that is ICD 10 and the transition to ICD 10. However, one thing that she said really struck a major chord with me during our discussion. She said…

“ICD 10 and Meaningful Use Don’t Focus Enough Incentives for Doctors.”

Basically, what’s the benefits for doctors to implement these regulations and changes? If you’ve ready me for any length of time, you probably have realized that I’m a doctor’s advocate. I strongly believe that some of the major reasons that EMR software hasn’t been adopted more widely is because far too many of the EMR software don’t put enough focus on the doctor.

Like it or not, Doctors are VERY powerful in their offices and can derail a project or make it succeed very easily.

This is why I agree completely that if you really want to affect change in the healthcare industry using EMR (or any other system), focus on benefiting the doctors and you’ll see amazing changes for good start to happen.

I’ve been hearing a bit of discussion about ICD-10 really helping to solve some of the problems of interoperability. Their contention is basically that ICD-10 is more precise in its description of the diagnosis and so therefore the information that is coded using ICD-10 will then provide more specific codified information that can then be rather easily shared. If you haven’t read about the transition from ICD-9 to ICD-10, here’s a good article about the transition.

In theory, this is completely accurate. If everything went as outlined, we could really get a lot of interesting information for studies and for interoperability of health data out of our ICD-10 codes.

The problem is that in reality ICD-10 is just going to cause even more problems for sharing quality data. Not because we can’t share the data. That’s a topic for a different discussion. The problem is that we’re never going to achieve quality input of diagnosis codes.

I’m not a doctor and so I’m not going to give a specific example here. However, I think all we have to do is look at the current ICD-9 diagnosing patterns. I’ve seen from first hand experience that often a doctor gets stuck searching for the right ICD-9 code. Right or wrong, they end up picking a code that may not be exactly the right code for what they’ve seen. Maybe they choose NOW (Not Otherwise Specified) instead of the specific diagnosis that would be more appropriate. Add in the complexity of diagnosis requirements for getting the most out of your insurance billing and I don’t think anyone would disagree with the assertion that ICD-9 code entry is far from accurate.

I’m not trying to place blame. I believe this is a chronic problem in our health system that those in the trenches have known about for years. My point here is that if we can’t get the rather “simple” set of ICD-9 codes right, then how can we ever expect the much more complex set of ICD-10 codes right?

Everyone knows the common phrase of garbage data in produces garbage data out. When we’re talking about interoperability of EHR software, doctors really have to think if they want other people’s garbage in their system.

ICD-10 really could produce some awesome information if used properly. The challenge we face is producing systems that codify the data properly so we have meaningful interoperability of healthcare data.