Doctors: ICD-10 Switch Inhibits "Meaningful Use" of EMRs

For a brief introduction to federal incentives for adoption of electronic medical records (EMRs), see yesterday's post.

In response to a request for comments on proposed rules for meaningful use, over 80 physician organizations joined forces behind a letter to the Office of the National Coordinator for Health Information Technology (ONCHIT). This letter outlines the unanimous opinion of these organizations on what the "meaningful use" criteria for EMRs should be.

The 80 organizations include the American Medical Association, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Radiology, the American College of Surgeons, the American College of Physicians, and numerous state medical societies.

In an attachment to the letter, these doctors' organizations note that in setting the timing of EMR implementation, ONCHIT should ...Factor in the Implementation of Version 5010, ICD-10, and Other Related Compliance Deadlines.

The attachment goes on to say:

The health care industry, including physicians, will be migrating to the next version of HIPAA electronic transactions standards,Version 5010, by January 1, 2012. Moreover, the transition from using ICD-9 to ICD-10 codes must occur by October 1, 2013 which is expected to be an even more complex undertaking than the adoption of the first version of HIPAA standards (4010) and the transition to use of the National Provider Identifier (NPI). The implementation timeframe must factor in vendor, physician, and other health care partner readiness for all of these significant transitions that will occur simultaneously with the incorporation of HHS’ recommended standards for qualifying EHRs.

Which ultimately means that physicians, in addition to hospitals, expect the switch to ICD-10-CM to slow them down significantly with respect to becoming "meaningful users" of EMRs.

Hospitals: ICD-10 Switch Inhibits "Meaningful Use" of EMRs

The "stimulus package"--more formally known as the American Recovery and Reinvestment Act of 2009--promises doctors and hospitals increased reimbursement from Medicare and Medicaid if they become "meaningful users" of electronic medical records (EMRs). Of course, the Act leaves open the definition of meaningful use, leading to yet another rulemaking process similar to the one that produced the mandate to switch to ICD-10-CM.

In its comments to the Office of the National Coordinator for Health Information Technology (ONCHIT), the American Hospital Association (AHA) correctly recognizes that the switch to ICD-10-CM will drain away resources from their efforts to become meaningful users of EMRs. In response, the AHA says that ONCHIT should slow down and lighten the criteria for "meaningful use."

The AHA comments (warning: pdf) say:

Staging the requirements and use levels in the definition also should recognize other HIT initiatives already underway and the likely vendor and workforce constraints hospitals may face. Hospitals are required to move to the new X12 Version of 5010 HIPAA standards in 2010 and ICD-10 in 2013. The AHA also is concerned that vendors will not be able to improve, test, implement and support HIT systems in hospitals nationwide due to the increased and simultaneous demand for HIT services and products. Vendor and hospital IT workforce capacity constraints should be considered as well.

In other words, the switch to ICD-10-CM will pull resources away from hospitals' ability to achieve meaningful use of EMRs.

A "monstrous task", "like a heart transplant."

These are the words of those who are starting to investigate the true cost and effort of switching to ICD-10-CM, as quoted in an article about the Healthcare Financial Management Association's annual Healthcare Finance Conference.

Orlando Health has found that the switch will affect 90% of all of its information systems. Integris Health of Oklahoma City has found that the switch will require "changes in data flow," "broad testing," and "intensive staff education".

The American Health Information Management Association (AHIMA), cheerleader for the switch to ICD-10-CM, recommends that you "establish a multi-disciplinary planning team involving all departments" now as a first step for making the transition.

If we're going to expend such resources to switch, why are we adopting a system whose core structure and framework is from the era of punchcards and paper charts?

In other words, if we're going to do a heart transplant, shouldn't we put in a good heart?

Diagnosis classification GEMs

The Center for Medicare and Medicaid Services (CMS) is sponsoring a conference call to discuss "ICD-10-CM/PCS Implementation and General Equivalence Mappings (Crosswalks)".

The purpose of the call is to discuss "...the General Equivalence Mappings that have been created to assist in converting policies, edits, and trend data from ICD-9-CM to ICD-10-CM/PCS."

In other words, to help the switch to ICD-10-CM from ICD-9-CM go more smoothly, CMS is betting on "General Equivalence Mappings" to help people convert their ICD-9-CM encoded data to ICD-10-CM encoded data. A transition plan might therefore involve continuing to code with ICD-9-CM and then converting those codes to ICD-10-CM. (!)

Sounds easy, right?

That is doubtful.

First, we want to point out the irony of this policy. We were told over and over that we'd get better data from ICD-10-CM coding and the sooner the better. Now, we're being told we can continue coding along merrily in ICD-9-CM and just convert our data to ICD-10-CM afterwards. How could that possibly result in better data?

Furthermore, to use the General Equivalence Mappings (or GEMs), you need to know the following facts, taken from the materials CMS posted for the conference call:

- ICD-9 and ICD-10 codes are quite different

- One ICD-9 Diagnosis Code may be represented by multiple ICD-10 codes

- One ICD-10 Diagnosis Code may be represented by multiple ICD-9 codes

- A few ICD-10 codes have no predecessor ICD-9 codes

- Some payers found GEM detail daunting, therefore they developed a "reimbursement mapping" which is much simpler. It is not clear when to use this mapping vs. GEMs.

- There may be multiple translation alternatives for a source system code (the code being looked up), all of which are equally plausible. This is true of both the ICD-10 to ICD-9-CM GEMs and the ICD-9-CM to ICD-10 GEMs.

- A one-to-one mapping does not imply that the two codes refer to the same disease!

- There are instances where there is not a mapping between an ICD-9-CM code and an ICD-10 code. In these instances, CMS has flagged the code with a "no map" flag.

- Each GEM has FIVE flags:
        1. The "approximate" flag
        2. The "no map" flag
        3. A flag to indicate a one-to-many mapping
        4. and 5. Two flags to "further clarify one-to-many mappings".

- CMS et al. developed GEMs "...independently without reference to Medicare data."

- The ultimate goal of the GEMs, and the primary basis on which they are maintained and evaluated, is whether a given patient record receives the SAME Medicare Severity Diagnosis Related Group. Essentially, this means that the improved diagnostic precision of ICD-10-CM is irrelevant to how Medicare will reimburse hospital stays.

- The net effect of the switch and the GEMs on "trend data" (for example, the incidence of hypertension or type 2 diabetes mellitus over time) is not known, and CMS will monitor the effect after the switch.

Why are we switching again?

ICD-10-CM cannot save the personal health record

In a Boston Globe article, several so-called experts obtusely suggest that the switch to ICD-10-CM will improve the quality of data in personal health records.

First, we must briefly say what is a personal health record (PHR). Then, we will recap the Globe story. Finally, we will illustrate that the use of ICD-10-CM in place of ICD-9-CM could not have helped the gentleman in the story.

Wikipedia defines a personal health record as ...a health record that is initiated and maintained by an individual. This definition does not account for the recent trend of companies like Google and Microsoft setting up personal health records, whereby health care providers and payers also contribute data to alleviate the amount of data entry required by the person.

The Boston Globe article recounts the story of Dave deBronkart, who set up a PHR with Google. Google helped transfer claims data into his PHR from a Beth Israel Deaconess Medical Center.

Mr. deBronkart was subsequently alarmed to see a diagnosis in his PHR of spread of his cancer to his brain or spine. You see, Mr. deBronkart has a history of kidney cancer. But it had previously spread to his skull, not his brain or spine. But there is no ICD-9-CM code for spread of cancer to the skull, so the experts quoted in the article understandably postulate that medical records coders used instead codes for spread to brain and/or spine.

But two experts, Drs. John Halamka and Roni Zeiger, then go on to claim that ...the records will improve as more precise coding language is adopted in the coming years. The article does not mention the particular coding system they had in mind, but since the data in question was claims data, it is hard to imagine otherwise.

So, could the switch to ICD-10-CM have prevented the unnecessary fright experienced by Mr. deBronkart?

NO.

ICD-10-CM has the C64 family of codes for malignant neoplasm of kidney (his primary cancer that subsequently spread to his skull), including C64.0 (right kidney), C64.1 (left kidney), and C64.9 (unspecified kidney).

It also has C79.31 - Secondary malignant neoplasm of brain and C79.51 - Secondary malignant neoplasm of bone.

But ICD-10-CM has no code for secondary malignant neoplasm of the skull.

You cannot use C41.0 - Malignant neoplasm of bones of skull and face, because that code must be used only for cancers of bone that arise in the skull and face, not for any cancer that spreads to the skull or face from somewhere else.

And that's it. There are no other even-close-to-relevant codes.

So much for any benefit to ICD-10-CM to help Mr. deBronkart.

Final rule for ICD-10-CM survives Obama administration review

HHS' final rule mandating ICD-10-CM has passed muster with the Obama administration. The rules will proceed unaltered, and thus the final compliance date for ICD-10-CM is Oct 1, 2013.

Hospitals, physicians, clinical laboratories, health plans, the federal government itself, state governments, nursing homes, and more will all now spend an estimated $1 billion to upgrade from a bad disease coding system to a slightly less bad, but unnecessarily more complicated, one.

Final ICD-10-CM rule likely on hold for review

The Obama administration has held for review all rules that either have not been published or have not yet taken legal effect. The latter condition applies to the final ICD-10-CM rule, because it does not take effect till March 17.

It's a long shot, but perhaps the review will lead the Obama administration to realize what a mistake the ICD-10-CM switch is.