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Getting Up to Code

October 28, 2008
by Daphne Lawrence
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While some wait for vendors to save them from ICD-10, savvy CIOs are taking the reins early

CIOs today are facing a slew of new government mandates, including the ICD-10 codes, mandatory CPOE and e-prescribing. While it may be easier to push those items to the back burner, when it comes time to make a strategic plan, smart CIOs are preparing now.
John glaser, ph.d.

John Glaser, Ph.D.

“One of your jobs as a CIO is to keep your ear to the ground and see what regulatory and legislative stuff is coming down the pike,” says John Glaser, Ph.D., vice president and CIO of Boston-based Partners HealthCare System. “What you don't want to do is wait and hope it will go away.”

Glaser says he believes both the government and the business community are getting anxious and perhaps even tired of waiting for the providers to make certain moves. “They're going to come in with sticks,” he says. “And we ought to be prepared.” Though many say they agree (and others say they hope) these mandates may be delayed by a year or so, Glaser says, “They're not going away.”
Rodney dykehouse

Rodney Dykehouse

Are some mandates more pressing than others? Rodney Dykehouse, who recently switched his CIO role from the Los Angeles-based UCLA Health System to the two-hospital ProHealth Care network in Waukesha, Wis., says it's difficult to put one in front of the other. “If they're time-dependant, and they usually are, we generally just back into those dates,” he says. Dykehouse joins many others in comparing these mandates to Y2K or HIPAA. “If it's regulatory, we put it in the must-do category,” he says. “At some level, it becomes a cost of doing business and other discretionary items are delayed.”

And that cost can be high. According to Rajiv Sabharwal, principal and chief solutions architect, Infosys Healthcare Consulting, a global company with United States headquarters in Fremont, Calif., the industry-wide financial impact of ICD-10 will be roughly $12 to 30 billion. Even a local, statewide mandate such as CPOE can be $50 to 70 million, he says.

Where is that cost coming from? For ICD-10, Sabharwal says there are three types of financial impact: training for coders, applications for systems, and lastly, the loss of productivity that will inevitably occur. “Right now on ICD-9, a coder can code three to three-and-a-half transactions a minute,” he says “With ICD-10, for the first six months anyway, the expectation is that it's going to go down to almost one to one-and-a-half.”

With impact like that, CEOs need to be brought in early. Glaser gives a heads up to those in leadership roles, warning them of what's coming, what it means, and the magnitude of what they're going to be in for, helping with planning capital and operating budgets. “You can certainly alert the CEO (who has not) done a whole lot of planning so it's on his or her radar screen.” He adds, though, that going to the Board is a different story: “In a nanosecond, they're going to ask, ‘What are we going to do about it and how much is it going to cost?’ So you want to have a reasonably well-thought-out plan.”
Stephanie reel

Stephanie Reel

Most say the first step in that plan is an enterprise assessment. At ProHealth, Dykehouse is doing just that. “We are early in our review and assessment of what our systems can and can't do,” he says.

Another jumping off point for CIOs is using quick time criteria — what CIOs can do first, quickly and get out of the way — Sabharwal says. He adds that the planning can be broken down into multiple pieces, especially if CIOs have to outlay significant capital just to identify the extent of the impact.

According to Dykehouse, it's important to follow a logical evaluation in terms of the actual systems, and also from a process standpoint. “That analysis needs to take place in conjunction with our vendors, so it really is a partnership with our internal clients, our vendor and IT in order to meet those requirements in the defined period of time.”

For mandates like ICD-10, many say the internal clients will be doing the heavy lifting. Stephanie Reel, vice president and CIO of Johns Hopkins Hospital and Health System in Baltimore, says much of the real work on mandates will be done down in the weeds, with patient accounting, medical records and other directors making sure their staff is trained. “There is an enterprise-wide commitment to many of these regulatory requirements, but the fulfillment is done at a local level,” she says. “So it masks the visibility of (the mandate) a little bit because it's being absorbed at the local level.”

Reel says she counts on the team leaders in the operating units to keep a finger on the pulse of what is going on across the nation. “When Medicare or Medicaid comes out with changes, it's a business partner that sits down with an IT leader, and they decide what needs to be done, and what doesn't get done.”

At ProHealth, Dykehouse plans to follow a similar path. “We're not the business experts, so we work internally with the key departments like finance and coding and begin to pull them into the analysis,” he says. “The internal business owners really need to understand the implications of going from 17,000 codes to 155,000.” According to Dykehouse, it is the IT department, however, that has the more direct relationship with the vendor and, therefore, the responsibility to coordinate a review with the business owners and with the vendor itself.

And since many expect the vendors to be of paramount importance for large-scale changes like ICD-10, the vendor-provider relationship needs to be strong. “Our expectation is that they are our partner; they are doing work for 100 hospitals, and we're one of 100,” Reel says. “It's fair to say it's a partnership.”

Vendor expectations

Like many other CIOs when it comes to mandates, Dykehouse has expectations for his vendors. “We expect the vendor to be current with regulations,” he says. “In partnership with them, we want to get up to speed very quickly.” Still, he says, it's important to keep an eye on the direction the vendor is taking, because it may not be aligned with the organizational strategy. “We expect the vendor to provide for us, but we don't take it on pure faith.”

However, not everyone expects the vendor to provide solutions. Sabharwal says the sheer number of vendors is going to make conversion difficult, because not all of them may provide solutions. He says he believes some vendors will use ICD-10 as a way to push (and sell) new modules. Even the best case scenario has problems. “Though the vendors may have good intentions, and come out with modules free of cost, implementation is going to vary over a period of time,” he says. “CIOs have to think out of the box and start thinking that the solution may not exist with their vendor.”

For ICD-10 conversions in particular, Sabharwal believes, CIOs need to look beyond their EMR vendors. “EMR vendors are there for clinical data management and they will do (ICD-10) in a half-hearted manner because that's not their primary business.” He says the majority of the vendors won't give the upgrades free of charge because many contracts exclude regulatory requirements. And even if the vendor does bring out new modules, Sabharwal asks, what is their responsibility? “They're not helping you train your staff,” he says.

Sabharwal's advice? Don't be complacent about the vendor providing a solution.

But mandates like ICD-10 can come with a silver lining, much in the way Y2K gave hospitals a chance to replace old systems that needed attention. According to Glaser, since ICD-10 codes are more fine-grained, there will be better reporting and analysis, which CIOs can leverage for their benefit. “Try and find a way of leveraging this to improve the quality of your data, improve the quality of your old systems, or tighten up controls.”

Reel says CIOs are in a better position today than when Y2K rolled in. “We're more malleable than we've been in the past, and better able to respond, because we've built an infrastructure, be it people or technology,” says Reel, who likens managing the IT infrastructure to building a home. “We have finally gotten to the point, in many areas, where the foundation is strong enough that we can change the doors or move the walls without rebuilding the whole house.”

And there is more good news that many CIOs may not even realize. Glaser reminds CIOs that with mandates, getting an “A” doesn't matter. “You want to pass, so a “C” is sufficient here,” he says. “You want to do enough to comply with the mandate, but nobody gets extra credit for going above and beyond.” How does a CIO figure out what that minimum is? Glaser says that's part of the initial assessment and analysis. “The key point is you just need to pass.”

Glaser says getting an early read is key. He encourages following the work of HIMSS and CHIME advocacy groups and the eHealth Initiative, among others, as a very important part of a CIO's job to attain that early read. “And the other job is judgment — and your judgment can come because you talked to consultants, or you read Healthcare Informatics.”

Sabharwal offers some final advice: “Do not restrict yourself to obvious systems or you will get hurt.” For ICD-10, the obvious system would be revenue cycle, but he says every single system will be impacted. “If you are coming out with an EHR tomorrow, or are part of a RHIO, you won't be able to provide info unless you're using ICD-10,” he says. “Cover every possible angle, and do not be complacent about your vendor providing a solution.”



  • For mandates, a passing grade is good enough — don't over-do.

  • Alert the CEO early, but wait for a plan before going to the Board.

  • Partner with end-user departments.

  • Don't rely on your vendor to prepare for government mandates.

  • Utilize information from CHIME, AHIMA and peers.



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Healthcare Informatics 2008 November;25(11):26-28

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