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Is ICD-10 a Quality Initiative?

August 27, 2010
by David Raths
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Innovators Will Use ICD-10 to Further Their Business Models and Clinical Capabilities


As health providers prepare to make the transition to ICD-10 and HIPAA 5010, they are taking a hard look at who, within their organizations, will lead the efforts. Whoever takes the lead will be deciding on a key question: Will the transition be an opportunity for quality improvement?

An interesting paradox surrounds the efforts to motivate hospitals and physician practices to get moving on the transition to HIPAA 5010 and ICD-10 codes. Much like the period before the Y2K conversion or HIPAA's introduction, analysts and consultants have largely succeeded in convincing providers of the magnitude of the challenge. Yet despite this heightened awareness, very few organizations have made progress on ICD-10, and some CIOs are getting nervous about it.

“We started this process more than a year ago, and we are not nearly as far along as I thought we would be,” says Bill Spooner, CIO of San Diego, Calif.-based Sharp HealthCare, a five-campus, 2,000-bed system.


Most people who work in health IT don't need another primer on the specifics of the challenge. Healthcare Informatics published one just last December under the headline “Wait at Your Own Risk.”

Bill Spooner
Bill Spooner

CIOs know that ICD-10 coding, a federal requirement by Oct. 1, 2013, will allow for far greater detail in classifying diseases by increasing the 17,000 codes in ICD-9 to 155,000. The transition has the potential to improve disease management efforts and quality data reporting.

Health IT and finance executives also recognize that the switch will require investments in training, changes to legacy systems, and testing with partners, vendors and payers. In addition, it will necessitate a technological “crosswalk” between ICD-9 and the new ICD-10 codes to ensure system compatibility during the transition timeframe.

The real questions now involve who within the organization will lead the effort, and will it be seen in the context of an innovative quality improvement program or treated as a matter of regulatory compliance only. What are teams that got started early working on now?

Sharp's ICD-10 team has 10 members led by an IT project manager, with the chief financial officer of one of Sharp's hospitals as an executive sponsor. “My team is facilitating it, so I guess we are taking the ball on this,” Spooner says, “but we haven't turned up the fire on it yet.”

The first thing the Sharp ICD-10 team did was try to create an inventory of the type of employee training that will be necessary and a survey of its business partners. “Our main software vendors seem on top of it, and could give us specifics about their roll-out plan,” Spooner says, “but some small vendors seem less prepared. And the answers from health plans were less than satisfying,” he adds. “Some are changing their software, while others are doing some kind of tricky software plan to convert the codes back to ICD-9, which may undermine the whole purpose.”

Sharp is in the minority in having its CIO's office taking charge of the effort. A February 2010 survey of 37 healthcare executives by Falls Church, Va.-based consulting firm Noblis found that CFOs are leading 52 percent of project teams while CIOs are leading 15 percent.

Getting Ready for ICD-10

Who has responsibility for ICD-10 in your organization?

Source: February 2010 Noblis Insights Panel survey of 37 healthcare executives.
Source: February 2010 Noblis Insights Panel survey of 37 healthcare executives.

Mary Anne Leach
Mary Anne Leach

“CIOs are really in charge of the HIPAA 5010 change because that is much more of a systems issue, whereas ICD-10, while involving systems, has a tremendous financial impact,” says Catherine Veum, senior manager in Noblis’ Health Innovation division, which is working with the Department of Health & Human Services on its own ICD-10 needs. “If hospitals or partners are not ready, there will be delays in accounts receivable days,” Veum adds. “That could put a hospital out of business.”



In Noblis’ survey, 48 percent of respondents were either unsure or believe that their organization is not on course to successfully prepare for the implementation of ICD-10. “We believe that provider organizations are dealing with so many other pressing issues, such as the new health reform law and HITECH Act, that they are distracted,” Veum says. “That is taking a lot more of their attention now.”

That assessment drew agreement from Mary Anne Leach, vice president and CIO of the 250-bed Children's Hospital in Aurora, Colo. “We have a lot of balls up in the air with meaningful use and certification issues,” she says. “But there is a recognition that we have to develop an ICD-10 migration strategy to get this done.”

The director of health information management is leading the Children's Hospital's readiness assessment, and a senior analyst from IT is analyzing requirements. “We haven't formally designated an officer to lead the effort, but I think it would make sense for our chief quality officer [Dan Hyman, M.D.] to take the lead,” Leach stresses. “This is in the end about granularity of information to improve care, so at some point it becomes a quality initiative. These initiatives succeed because we have strong clinical leaders.”

Veronica Vela, lead engineer within Noblis Health Innovation, says providers must decide if they are going to be compliance-focused or if they will see the ICD-10 implementation strategically and use the data in transformational ways to improve quality. “That will guide their efforts, timing, and use of resources,” she says.

Margaret Gaskill
Margaret Gaskill

Indeed, a 2009 report by the Deloitte Center for Health Solutions breaks down healthcare entities into pragmatists who will do the bare minimum required by law (60 percent, according to Deloitte estimates); collaborators, who will exceed basic compliance (20 to 25 percent); and innovators, who will use ICD-10 to further their business models and clinical capabilities (10 to 15 percent).

This last group, Deloitte says, will see ICD-10 as a catalyst to improve in several areas, including data capture, cleansing, and analytics. “This could lead to the development of advanced analytical capabilities, such as physician scorecards, insightful drug and pharmaceutical research, and improved disease and medical management support programs, all of which create a competitive advantage,” the report notes.



The larger a health system is, the more vendors it has and the greater the challenge of testing all the systems and changes to interfaces. A majority of respondents to the Noblis survey said their organization would need to rely on external help to prepare for ICD-10. One firm that provides such help is Nashville-based IT services firm eMids Technologies.

After hospitals and health systems do an analysis of all the relevant business processes and the applications that support them, then they must segregate out which application changes are being handled by the vendors and which need to be done in-house or by an outside service provider, says Prithwiraj Dasgupta, eMids’ vice president of practice management. “We have been asked by some providers to play the role of central coordinator,” says Dasgupta. The next step, he says, is to develop a timeline so that the testing of these changes can take place in a timely fashion.

He also believes that forward-looking CIOs will see beyond the mandate and view the transition as a longer-term opportunity to use data to drive efficiencies and improve care outcomes. “In that view, the transition is only an intermediate goal,” he says. “If your end goal is how you are going to use that data, then the steps you take now reflect that larger design and scalability.”

Some people may be underestimating the amount of testing ICD-10 is going to require, and the amount of time that will take, says Steven R. Barry, senior principal with Noblis. “CIOs have to keep track of when all those vendors and organizations are ready to test with,” he says. The medium-sized to large hospitals have to think about the specialty cardiology databases, cancer registries, and clinical trials data in their data warehouses. “Those are full of ICD codes,” Barry says. “Those won't be converted from 9 to 10, but if you want to do trend analysis over time, you will have to map to ICD-9 codes.”

Independent physician practices also realize that ICD-10 will be disruptive initially. Margaret Gaskill, the billing/EMR systems manager at Mercer Medicine, a multi-specialty physician group practice in Macon, Ga., knows that, at least initially, coders will have to get back to doctors for more information in order to code correctly. “I foresee a slowdown in revenue as physicians, staff, insurance companies, and Medicare/Medicaid all adjust to the new coding structure,” she says. “While you can plan for decades, you won't know the actual impact until you open your doors and see how all parts of the business mesh together.”

Gaskill is working with Mercer's EMR vendor e-MDs (Austin, Texas) and its Atlanta-based clearinghouse Navicure on transition planning. Here is her tentative schedule:

2010: Staff training on anatomy and physiology as pertains to ICD-10 coding.

2011: Staff training on crosswalks, coding by ICD-10, and begin to crosswalk the most-used codes.

2012: Physician training on coding by ICD-10 and what information they will have to give coders that they don't currently do. Continue staff training.

2013: Advanced training for staff and physicians utilizing a training module from e-MDs.

The scope of the change management aspect of ICD-10 is worrisome, says Leach of the Children's Hospital. “Figuring out every process and workflow this touches and where the training should be done is difficult. We can't train the work force fast enough. It is a really challenging time to be a CIO,” she says, before quickly adding, “but an exciting time, too.”

Healthcare Informatics 2010 September;27(9):24-28

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