EXECUTIVE SUMMARY
CIOs and HIM directors are laying the groundwork for the ICD-10 transition by performing critical risk assessments, beginning training programs for clinicians and coders, and figuring out what all this is going to cost.
Last October, Stephen Stewart, the CIO of Henry County Health Center, got a major wakeup call after he attended an ICD-10 sunrise session at the College of Healthcare Information Management Executives (CHIME) Fall Forum, which emphasized that the compliance deadline was quickly advancing. Before then, his 74-bed hospital in Mount Pleasant, Iowa, had, as he puts it, been “plodding along” on creating an ICD-10 plan, but after hearing the session, he sprang into action and called his health information management (HIM) director to start the ball rolling on a plan to tackle this multi-faceted project.
If your organization has been hearing similar calls to action, you're not alone. IT leaders and HIM professionals across the country are pursuing parallel paths that will eventually dovetail as the Oct. 1, 2013 ICD-10 transition date nears. These two departments will be joining other organizational leadership to work out detailed assessments of what systems will be affected and extensive ICD-10 training, all the while overcoming common challenges including budget, bandwidth, and human resources. As many have asserted, the technical issues of the ICD-10 transition are not that great; it's the training of clinicians and coders that will be the significant obstacle.
Because the ICD-10 transition cuts across all departments, Janice Jacobs, director, regulatory compliance practice at IMA Consulting (Chadds Ford, Pa.), says that every organization might take a different approach, but that, however they approach it, healthcare IT leaders “absolutely, positively have to have an executive steering committee.” At the very least, steering committees need to have representation from IT, revenue cycle, HIM, and clinicians to create a comprehensive communication plan to coordinate software upgrades and training, she advises. Organizations like CentraState Healthcare System, a 282-bed hospital-based organization in Freehold, N.J., and the 562-bed Fletcher Allen Health Care in Burlington, Vt., have gathered together multi-disciplinary taskforces to develop work plans and organize organizational assessments for their ICD-10 journey.
SYSTEMS INVENTORY AND PHYSICIAN DOCUMENTATION
All of the organizational leaders interviewed for this story note that a major component of their work plan has been a complete systems inventory to identify which information systems would be affected by the transition and what hardware and software upgrades would be necessary. “It's amazing when you start looking at the tentacles of ICD-10 and how it really cuts across all parts of your organization: financial, clinical, HIM, IT,” says Chuck Podesta, CIO, Fletcher Allen Health Care. “Depending on what type of systems you have in place, it can be even more challenging from an IT perspective if you're a best of breed versus an integrated shop because you have more systems.”
Many in the industry realize that considerable challenges will arise from physician documentation issues. Stewart acknowledges that physicians, when building problem lists at intake, will be confronted with more choices and clinical vocabulary with ICD-10. His strategy is to advise clinicians to document by their best practices, and HIM will review and correct the codes afterward. Over time, he says, his team will educate physicians on what additional coding they might be missing.
Lahey Clinic, a health system that includes a flagship 317-bed hospital in Burlington, Mass., as part of its clinical documentation improvement program for capturing quality data for benchmarking, did a risk assessment with the help of the St. Paul, Minn.-based 3M a year ago that identified ICD-10-driven documentation requirements for diagnosis codes and procedure codes, as well as what service lines required additional documentation specificity. Three hundred records were reviewed, says Lori Jayne, Lahey Clinic's HIM director and privacy officer, to target subspecialties and diagnosis-related groups (DRGs) that were lacking in documentation for the specific codes for ICD-10 translation.
The risk assessment revealed common threads that were lacking in physician documentation that included identifying the specific diagnosis or procedure involved. Another need that was identified was making sure laterality is documented for the site of joint replacements, cataracts, neoplasms, arthritis/osteoarthritis, hearing loss, and visual loss. Other items noted in the assessment include procedure codes needed in ICD-10 when none was required in ICD-9, and increased specificity needed in ICD-10 for some routine procedures that only had one code in ICD-9, such as for infusions/transfusions. Lahey Clinic will also be focusing on specialties like cardiology, orthopedics, and radiology, where coding guidelines and further training will be given.
BUDGETARY CONSTRAINTS
One area of uncertainty in all of this is how much an ICD-10 transition will cost. Among those who are scratching their heads are leaders at CentraState Healthcare. During budget planning last year, HIM Director Judy Gash put a preliminary figure into the budget for ICD-10 services, but it was quickly blown out of the water after ICD-10 risk assessment requests for proposal came back.
The quotes from the five vendors that submitted ranged from $100,000 to $600,000 and left Neal Ganguly, vice president and CIO, as well as the state's CHIME StateNet vice chair, perplexed. His committee is now drilling down into the proposals to see how much of what's recommended really needs to be done. At last year's CHIME Fall Forum, Ganguly remembers being astonished when hearing quotes of an ICD-10 transition costing in the millions for a community hospital. “We're trying to validate some of that because that just seems way off the mark from our perspective,” he says. “There's a lot of work that needs to be done, but I don't know if it's at that scope. One of our concerns is, are we missing something?”
Five Things You Can Do to Start Your ICD-10 Transition
CIOs and HIM directors cite several things that you can do to begin your ICD-10 journey today:
Perform a comprehensive impact assessment and systems inventory to identify which information systems will be affected by the transition and what hardware and software upgrades will be needed.
Decide if you have the internal talent to manage this multi-disciplinary project or if you have to outsource a project manager.
Educate a super user on the clinician and the coding side with a program like AHIMA's Academy for ICD-10.
Identify the top diagnoses and procedures within your organization and create “before and after scenarios” that show the specific wording and codes necessary for ICD-10.
Be realistic about future coding needs and be creative about recruiting and retaining your human capital.
Another wrinkle related to budgetary issues is whether to outsource the management of an ICD-10 transition, or marshal the resources internally. “Organizations are realizing now that they can't pull their existing pool of resources and devote them to work on ICD-10 all the time,” says Jacobs. “More and more organizations are outsourcing to outside vendors.” She says that in the past month she has gotten more requests for proposal than all last year put together.
“The key thing is identifying if you have the strong, disciplined project management expertise inside your doors, or not, because that's where you're going to need the help because ultimately this has a direct impact on reimbursement which makes all the difference in the world,” Ganguly says.
IMPLEMENTATION AND TRAINING
Podesta says that the key to ICD-10 training is to start physician awareness and education early. His team has created “before and after scenarios” for specific procedures and diagnoses that show the specific wording and codes necessary for ICD-10. “We're doing that with a small group now to gauge the impact,” he says. “But we think it's going to be huge because all the systems downstream will be affected by how well that documentation is done.”
Not only will clinicians need to be trained in ICD-10 documentation, coders will also need significant education. “The big difference with ICD-10 is that it's not just expanding a field two digits; it is a completely different coding methodology,” says Jacobs.
Some organizations, such as CentraState Healthcare, are already providing anatomy and physiology training for their coders. CentraState also sent several physician informaticists and executive team members to a four-day ICD-10 boot camp sponsored by the New Jersey Hospital Association. Future plans are for a high-level coder to be trained by the American Health Information Management Association (AHIMA) as a certified ICD-10 trainer to help prepare the organization's other coders. Jacobs says 2011 is the time for awareness-building, but still too early for ICD-10 coding training, as coders won't be able to actually start coding till 2013. She recommends starting to train six to nine months before the transition, so codes are fresh in coders' minds.
With the knowledge of a possible shortage nearing as older coders retire before the ICD-10 transition and with the industry's competitiveness, Jayne recommends organizations be creative in sustaining their coding resources. Her organization, Lahey Clinic, has established a remote coding program to recruit and retain coders that gives them several tools to infuse into their daily work. One tool, a crosswalk methodology, allows coders to see how today's ICD-9 codes will translate into ICD-10. Lahey Clinic has also implemented a computer assistive coding application to assist with abstraction of the entire medical record, which abstracts key medical terms and allows coders to validate the information. Other organizations, like CentraState, plan to hone in on their top diagnoses to see how much they will change from ICD-9 to 10, which will then guide future physician education.
Healthcare Informatics 2011 September;28(9):18-22
