Thursday, November 5, 2009

ICD-10-CM and Windows ME: A Switching Analogy

Much of the lack of resistance to the switch to ICD-10-CM is based on the presumption that since it is the next "version", it simply must be better. Proponents deride the arguments against the switch as being analogous to the question "MS-DOS works fine, why Windows?"

However, a better operating-system analogy would be "Windows 98 works fine, why Windows ME?"

As those who upgraded to Windows ME can attest, the upgrade was a complete disaster. PC World rated Windows ME as the fourth worst tech product of all time.

Analogously, ICD-10-CM is the last upgrade for the archaic, "statistical classification" architecture of terminologies. ICD-11 will use modern approaches to terminology.

In this sense ICD-10-CM is very much like Windows ME, in that Windows ME was the last MS-DOS based Microsoft OS before Microsoft converted its home OS to the newer, Windows NT architecture.

How ironic.

As naysayers against ICD-10-CM, we are saying that we should skip ICD-10-CM, which is the Windows ME of disease classification. It is the proponents of ICD-10-CM who are arguing for the perpetuation of ancient technology, not the naysayers.

Wednesday, October 7, 2009

The cost of the switch, briefly revisited

Prior efforts to estimate of the cost of switching from ICD-9-CM to ICD-10-CM compared the cost to that of Y2K remediation. In a post last year, we also highlighted the comparison.

The American Hospital Association estimates that the cost of Y2K was $8 billion for hospitals. Compare that to the Health and Human Services (HHS) estimate for switching to ICD-10-CM of $1.6 billion.

Now comes the experience of someone who lived through Y2K and now is preparing his hospital for the government-mandated switch.

Stanley Padfield, system director for health information management at four-hospital Lee Memorial Health System, Cape Coral, Fla, considers the cost of the switch to be higher than that of Y2K remediation.

An article describing Padfield's experience notes:

Padfield says tackling the ICD-10 challenge will prove more difficult than Y2K “because there are a lot more variables involved.” Plus, providers that fail to adequately prepare risk not getting paid promptly by Medicare and other payers.

So, the early experience is already that the ICD-10-CM switch will cost hospitals more than the $8 billion they spent on Y2K. Which dwarfs the HHS low-ball figure of $1.6 billion for the entire health care system to switch.

Even the optimistic RAND report that analyzed the cost of the switch could not come up with more than $7.7 billion in benefits to the switch.

So the early signs are that the costs of the ICD-10-CM switch to the health care system will far exceed the benefits.

Monday, September 7, 2009

Background on disease classification and coding

The Encyclopedia of Public Health on has two, concise articles on classification of disease and its history.

For a concise overview on the general task of classifying diseases and the reasons for it, see the Classification of Disease entry.

For a history of disease classification and the International Statistical Classification of Diseases and Related Health Problems (now the official name for ICD, including ICD-10), see this article.

Monday, July 20, 2009

"Meaningful Use" criteria require problem lists in ICD-9 or SNOMED

As we discussed in previous posts here and here, the "stimulus bill" passed by Congress earlier this year increases Medicare and Medicaid payments to physicians and hospitals who are "meaningful users" of electronic medical records (EMRs) in coming years.

The linchpin to the payments is the definition of "meaningful use", which the law mandates that the Department of Health and Human Services (HHS) define. The law also mandated the formation of the Healthcare Information Technology (HIT) Policy committee, and it is this committee that is currently conducting hearings into what the criteria for "meaningful use" should be. Ultimately, HHS will define meaningful use through a rulemaking process similar to the one that led to the mandate to switch to ICD-10-CM.

Well, the latest "matrix" (warning: pdf) of meaningful use criteria stipulate that the EMR must maintain problem lists in either ICD-9 or SNOMED.

We think they are both terrible choices. Problem lists maintained in either system are not likely to be very meaningful at all.

Tuesday, June 30, 2009

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.

Monday, June 29, 2009

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.

Thursday, June 18, 2009

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?

Wednesday, May 6, 2009

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?

Monday, April 13, 2009

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?


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.

Thursday, March 12, 2009

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.

Monday, January 26, 2009

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.

Tuesday, January 20, 2009

The 318 ICD-10-CM codes for diabetes mellitus

In a previous post, we pointed out that despite the fact that there are very few known subtypes of diabetes mellitus, ICD-10-CM has approximately 290 codes for diabetes mellitus, not counting gestational diabetes mellitus.

In the 2009 release of ICD-10-CM, we count a total of 318 codes for diabetes mellitus, including gestational diabetes mellitus. The reason for the large number of codes is that ICD-10-CM combines multiple disease classes into a single code.

For example, the ICD-10-CM code E11.621 Type 2 diabetes mellitus with foot ulcer, contains two disease classes: diabetes mellitus and foot ulcer. For sure, this code implicitly means that the former caused the latter (note that this causal relationship is inaccessible to the computer), but that augments our point. Nothing is its own cause and thus these two diseases are distinct.

We provide here on Google docs the 318 codes and their text strings, in a spreadsheet format that anyone can at least copy-and-paste into their own spreadsheet or database table. An easy way to demonstrate the needless complexity caused by combination codes.

Sunday, January 18, 2009

Myth: SNOMED CT has more disease codes than ICD-10-CM

Because SNOMED CT is a reference terminology, and ICD-10-CM a disease classification, one might think that SNOMED CT would have more disease codes because it reaches a higher level of diagnostic precision (what the ICD-10-CM proponents ambiguously refer to as "specificity") than ICD-10-CM.

One would be wrong, however. We already busted this myth in a previous post, but we give it its own post to highlight the absurdity that is ICD-10-CM.

Per the final rule (warning: pdf) to adopt ICD-10-CM, ICD-10-CM has approximately 68,000 codes. SNOMED CT (the July, 2008 version), by contrast, has 63,731 active disease codes.

ICD-10-CM therefore has approximately 7% MORE disease codes than SNOMED CT. Assuming of course, that ICD-10-CM contains only codes for diseases, which it doesn't. It has codes for lots of other things, like symptoms of disease. If there were any way to count automatically how many ICD-10-CM codes represented diseases as opposed to something else, it would be possible to do an actual apples-to-apples comparison.

But, since ICD-10-CM says it classifies diseases (and not other things) and gives no way to infer automatically (i.e., by computer) whether it classifies other things than disease, we feel justified in making this comparison. It highlights another absurdity of ICD-10-CM: it isn't (entirely) what it says it is.

Friday, January 16, 2009

It's final: ICD-10-CM by Oct 1, 2013

The Department of Health and Human Services issued today a final rule (warning: pdf) mandating the adoption of ICD-10-CM as a code set under the Health Insurance Portability and Accountability Act (HIPAA). It pushed back the deadline from Oct 1, 2011 (from its proposed rule last August) to Oct 1, 2013.

At approximately the same time, the National Center for Health Statistics released a new, 2009 version of ICD-10-CM that is available here. Instead of the 23MB, 2,392 page PDF file of the 2007 format, we now have an 8.8MB, 2,369 page PDF file. A trimming of 1% on the page count, and a shrinking of over 50% in file size.

The health care industry now has a little more than 4.5 years to find every usage of ICD-9-CM codes in all of its systems, and upgrade and test them to use ICD-10-CM. All the effort spent on that, will not be spent on adopting electronic medical records, devising and participating in pay for performance programs, improving patient safety, automating the reporting of notifiable diseases, chronic disease management, quality initiatives, adopting other information technology standards for true interoperability, and the list goes on.

ICD-10-CM fails every basic requirement demanded of modern technology, terminology, and ontology, and yet it--and previously ICD-9-CM which also fails to meet these requirements--are the only code sets the government has mandated the industry adopt en masse. We suppose it's not surprising coming from a government bureaucracy. But it still is senseless.