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Drawing Detailed Codes: Q&A with the Creator of ICD-10 Illustrated

November 5, 2014
by Gabriel Perna
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Credit: ICD10Illustrated.com
Being situated in one of America's health IT hubs and having worked for one of the largest health IT companies in the world means spending a lot of time thinking about health IT.
 
That is the case for Nikolai Skievaski, who is based out of Madison, Wisc. For more than three years, Skievaski worked for Epic Systems, the large electronic health record (EHR) developer based in the Badger State's capital city. He worked with company executives to look for innovations. 
 
Within Epic, he started a searchable knowledge base platform that allows people to better understand how the software works. Eventually that idea became the basis for Breadcrumbs, an offshoot company that he left Epic to start in 2010. Since leaving Epic, the entrepreneurially-minded Skievaski has managed Breadcrumbs while starting both health IT-related and non-health IT companies.

One of his entrepreneurial successes has caught the attention of government officials, health IT observers, and mainstream      media outlets like The New York Times. It's a collection of art that depicts instances of ICD-10. As most know, the 60,000-plus ICD-10 codes are famously detailed and Skievaski's book, Struck by Orca: ICD-10 Illustrated, is a humorous take on the code descriptions. He has brought in healthcare and non-healthcare contributors for various illustrations within the book. The book has become such a hit (nearly 10,000 copies sold) that he has expanded the idea to Stage 2 of meaningful use. 

Healthcare Informatics Senior Editor, Gabriel Perna, recently had a chance to discuss the book with Skievaski. Below are excerpts from that interview. 
 

Nikolai Skievaski

Where did the idea for the ICD-10 illustrated book come from?
 
This is the health IT heartland. What we do when we have fun is we nerd out about healthcare regulations and stuff like that. There was a group of 10 of us sitting on a blanket in the capital square green area, hanging out in the summer. The conversation got to ICD-10 for some reason. Everyone pulled out their phone and started listing off the funny ICD-10 codes, which I think is a pretty common occurrence. Any time someone talks about ICD-10 they pull up some of those ridiculous codes. Someone said, "We should make a children's book that have the codes in them." We all laughed and thought it was funny. Like many ideas among friends over beers, nothing happened with it.
 
Come October of that year (2013), I was talking with another one of my friends from that group. He wanted to know if I had done anything with it. I told him no. He said, "I'll draw a picture." So he drew the first illustration for it. From that, I showed it to other artists in the healthcare space and they got a kick out of it. That kind of validated that it was more than just an idea over beers. People started sharing it. That's when we realized we can make this into a book. 
 
Beyond it just being fun, it showcases great art. What we really love about it is it points out, in a tongue-in-cheek way, what's going on in healthcare. Reform is dragging the industry down and making the industry move more slowly than we'd like it to be. ICD-10, there are pros and cons with the main con being it's a big change that everyone will have to get used to. The change is hard. We're not trying to say ICD-10 is good or bad with this book; it's an artistic outlook on the regulatory change in healthcare. 
 
How do you recruit artists? 
 
All of the art in the book was done by a different artist that volunteered to do it. The artists range from physicians or people who work in healthcare who are not really artists but they like to draw, the bad art, all the way professional artists who don't know about healthcare. We explain what's going on to them and they love it. In the book, there are write ups from different artists. We have people work at Epic, different health systems, other EHR vendors, and medical billing coders. It's a good variety. 
 
Who is the book meant for? 
 
When we initially launched, we thought it would attract a small, select niche audience of people who are into health IT. What we realized is that anyone in healthcare knows what ICD-10 is or is affected by it. It affects the whole health system, top to bottom. So our audience included nurses, doctors, care providers...the market was wildly bigger than we thought it would be. Our initial order was 300 and we weren't sure if we'd sell them all. We've sold almost 10,000 books. The market was much bigger than we thought it would be.
 
What are some of your favorite codes/drawings?
 
Even before the book, one of the codes that people talked about was "Burned due to water skis on fire." How does that even happen? You're on water skis, how are you on fire? Did it happen to someone? I still haven't found that out. 
 

With that code, the artist who did it, she was on a go-live for Epic. It was probably 2 a.m. at the hotel room, she just got off her shift, and the deadline for the art was coming up. She used nail polish and chopsticks in her room to create the art. If you look at the art, it's phenomenal. It's like an abstract piece of a guy on water skis that are on fire. She did it with ketchup, lipstick, nail polish in a hotel room as she was supporting an Epic go live. It has a wonderful story to it and it's a beautiful piece. 

 

There are some that I just love the artistic quality. There's one that's, "Toxic effect of bee sting, intentional self harm." It's a ridiculous code. You're trying to commit suicide via a bee sting. Our artist who did it is actually a cartoonist for The Chicago Tribune. He's a professional cartoonish and you can tell. There's a guy in a bee outfit with a sign that says "goodbee cruel world" trying to off himself with bee stings. That's a great one.  Photo credits: ICD10Illustrated.com

 
What does Meaningful Use Stage 2 Illustrated entail?
 
We saw the success of the ICD-10 book. After ICD-10 was delayed back in March, sales dropped by two-thirds. It was no longer the biggest issue everyone was facing. So we said, "What else do we know? What's the biggest issue that health systems are facing?" Stage 2 of meaningful use is something that a lot of organizations are trying get set up for so they can attest. It's complex, there are a lot of metrics that people are trying to understand. We made our argument for Meaningful Use Stage 2 Illustrated, which is the meaningful use provisions copied from [the Centers for Medicare and Medicaid Services]. We got artists to illustrate the provisions. 
 
I think this book is more useful than the ICD-10 one. It gives you a full account of the meaningful use Stage 2 metrics. We also did a few things to make it more appealing to look at. The audience here is a lot smaller but it's the people who will find it useful. We started a little bit of a company around illustrating healthcare regulatory activities. It's nothing any of us were setting out to do but we realize it adds a little bit of value and satire to an industry that's fraught with regulatory bureaucracy. 
 
Any future projects on tap?
 
I'm not sure. That's up to CMS to decide. 

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