The Department of Veterans Affairs (VA) is spending $211 million on software and services for the switch to ICD-10-CM. And this expenditure is on a third-party alone, let alone the time its employees are devoting to managing the switch.
So, how does this dollar figure comport with the estimates that various entities made of the costs of the switch to ICD-10-CM?
Well, as it happens, it is well out of bounds of any of the estimates.
First, the RAND report (warning: PDF) that estimated the costs of the switch failed to account for any costs to the VA for the switch. Oops. The RAND report estimated a cost of $425–1,150 million for the switch, so this $211 million expenditure on the part of the VA inflates RAND's estimate by 19-50%.
Therefore, RAND's estimate of the overall cost of the switch is significantly low.
Next, the Department of Health and Human Services (HHS), in its final regulatory rule (warning: PDF) mandating the switch, did account for VA software expenditures to manage the switch. HHS estimated that the VA would spend a total of $24-31.35 million on software and systems, not counting training and planning. Even if we add training and planning (assuming that the contract includes those functions), HHS estimated no more than $113.8 million in spending on software/systems by the VA.
Thus, the $211 million figure is nearly double the amount that HHS expected, at a minimum.
HHS pegged total costs of the switch at ~$2.3-2.6 billion. So this overrun of its estimate for the VA represents 3.7% of the highest estimate by HHS for the total, national cost of the switch.
What other overruns are government agencies, providers, and payers experiencing. In other words, where else, and by how much, are the estimates too low?
Stay tuned.
We have always maintained that the estimates were unrealistically low, and now we have presented proof.
Showing posts with label switch to ICD-10-CM. Show all posts
Showing posts with label switch to ICD-10-CM. Show all posts
Tuesday, February 8, 2011
Tuesday, April 13, 2010
ICD-10-CM is NOT a nomenclature
In this article about the lengths to which organizations must go to 'upgrade' to ICD-10-CM, the author refers to ICD-10-CM as a 'nomenclature'.
ICD-10-CM, as its formal name indicates, is a classification, not a nomenclature. Its formal name is the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), as listed on the web site of the government agency that created it from ICD-10.
For example, ICD-10-CM code K83.8 refers to Other specified diseases of the biliary tract. This class of diseases includes multiple individual diseases such as: adhesions of biliary tract, atrophy of biliary tract, hypertrophy of biliary tract, and ulcer of biliary tract.
A nomenclature, by contrast, would have codes for each of these diseases that ICD-10-CM lumps together under the single code K83.8.
So, unfortunately, misinformation about ICD-10-CM continues. Were it truly a nomenclature, and a good one, then it would truly be a worthwhile upgrade.
ICD-10-CM, as its formal name indicates, is a classification, not a nomenclature. Its formal name is the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), as listed on the web site of the government agency that created it from ICD-10.
For example, ICD-10-CM code K83.8 refers to Other specified diseases of the biliary tract. This class of diseases includes multiple individual diseases such as: adhesions of biliary tract, atrophy of biliary tract, hypertrophy of biliary tract, and ulcer of biliary tract.
A nomenclature, by contrast, would have codes for each of these diseases that ICD-10-CM lumps together under the single code K83.8.
So, unfortunately, misinformation about ICD-10-CM continues. Were it truly a nomenclature, and a good one, then it would truly be a worthwhile upgrade.
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.
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.
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.
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.
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?
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?
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?
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.
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.
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.
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.
Wednesday, December 17, 2008
Myth: It is practical to assign ICD-10-CM codes manually
The proposed rule to mandate the switch to ICD-10-CM states:
It would be impractical to attempt to manually assign SNOMED–CT codes. The number of terms and level of detail in a reference of clinical terminology such as SNOMED CT cannot be effectively managed without automation,...
By implication, then, it would be practical to assign ICD-10-CM codes manually. Otherwise this supposed disadvantage of SNOMED-CT would not be a factor in HHS' decision to reject SNOMED-CT.
Let us examine this claim further.
ICD-10-CM, by all accounts we have seen--including the proposed rule itself, contains approximately 68,000 codes.
First, we think the very notion that the human brain can cope with 68,000 codes and reliably and manually assign a few of them correctly to patient visits or hospitalizations has no face validity.
Second, even with the manual assignment of the 13,000 codes of ICD-9-CM, there is and has been tremendous variability and low reliability. The Department of Veterans Affairs (VA) conducted a study that found substantial variability in assignment of ICD-9-CM codes:
Based on this study, OHI concluded that the coding of the primary and secondary diagnoses varied widely. The implications of this variability has to be considered when assessing the validity of health services research, health care program planning, quality assurance, utilization review, and resource allocation for VA Medical Centers based on ICD-9-CM codes or DRG information.
While OHI was not evaluating the coding "error rate" in this study, the coding variability observed in the study was comparable to error rates noted in earlier Institute of Medicine (IOM) studies. We found a 60.6 percent agreement in the primary diagnosis code among the original coders and our expert coder. The IOM studies documented a 65.2 percent agreement on the principal diagnosis code, in 1977, and a 63.4 percent agreement on the principal diagnosis code of the records analyzed in 1980. Thus, in all three studies there was approximately a 2/3's agreement in the coding of the medical record.
Even among the expert coders, there was a 19 percent disagreement on the primary diagnosis code. Since our expert coders were highly qualified, this high rate of disagreement caused OHI to question the reliability of the selection of the primary diagnosis and, thus, the accuracy of coded information.
A study of ICD-9-CM coding in psychiatry concluded:
The question was addressed how well mental health professionals were able to translate diagnostic formulations into ICD-9-CM codes. This was done with three coder groups and under two conditions. It was found that there was insufficient interrater agreement on the ICD-codes in all groups and conditions. This finding then was related to the inadequacies of the ICD-system itself. It was concluded that current mental health statistics that are based on the ICD-9-CM coding system are without scientific value.
A study of ICD-9-CM coding in intensive care concluded:
In a multicenter database designed primarily for epidemiological and cohort studies in ICU patients, the coding of medical diagnoses varied between different observers. This could limit the interpretation and validity of research and epidemiological programs using diagnoses as inclusion criteria.
Since other nations have already switched to ICD-10 or their own national variant of it (none of which has even half as many as 68,000 codes), what has their experience been with ICD-10? Better coding? No.
One study of the reliability of coding with ICD-10 concluded:
The refinement of the ICD-10 accompanied by innumerous coding rules has established a complex environment that leads to significant uncertainties even for experts. Use of coded data for quality management, health care financing, and health care policy requires a remarkable simplification of ICD-10 to receive a valid image of health care reality.
A study from Canada even compared the quality of coding between ICD-9 and ICD-10 and concluded:
The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM.
So then, manual assignment of ~13,000 ICD-9-CM codes in the U.S. and elsewhere, and the manual assignment of ~13,000-30,000 ICD-10 codes (depending on national variant), have not been "effectively managed".
It brings to mind the old adage, those who live in glass houses should not throw stones.
So what of SNOMED-CT? How many disease codes are we looking at?
The July, 2008 version of SNOMED-CT, by contrast, has 63,731 active disease concepts. [1]
SNOMED-CT, therefore, actually has fewer disease codes than ICD-10-CM! It is hard to imagine that manual assignment of SNOMED-CT disease codes could be managed any less effectively than manual assignment of ICD-10-CM disease codes.[2]
Myth: Busted.
[1]Because SNOMED-CT, unlike ICD-10-CM, comes in machine-readable format, these kinds of exact counts are easy to make.
[2]Note that we are not advocating SNOMED-CT for disease coding. And studies conducted thus far have shown lack of reliability in SNOMED-CT disease coding as well.
It would be impractical to attempt to manually assign SNOMED–CT codes. The number of terms and level of detail in a reference of clinical terminology such as SNOMED CT cannot be effectively managed without automation,...
By implication, then, it would be practical to assign ICD-10-CM codes manually. Otherwise this supposed disadvantage of SNOMED-CT would not be a factor in HHS' decision to reject SNOMED-CT.
Let us examine this claim further.
ICD-10-CM, by all accounts we have seen--including the proposed rule itself, contains approximately 68,000 codes.
First, we think the very notion that the human brain can cope with 68,000 codes and reliably and manually assign a few of them correctly to patient visits or hospitalizations has no face validity.
Second, even with the manual assignment of the 13,000 codes of ICD-9-CM, there is and has been tremendous variability and low reliability. The Department of Veterans Affairs (VA) conducted a study that found substantial variability in assignment of ICD-9-CM codes:
Based on this study, OHI concluded that the coding of the primary and secondary diagnoses varied widely. The implications of this variability has to be considered when assessing the validity of health services research, health care program planning, quality assurance, utilization review, and resource allocation for VA Medical Centers based on ICD-9-CM codes or DRG information.
While OHI was not evaluating the coding "error rate" in this study, the coding variability observed in the study was comparable to error rates noted in earlier Institute of Medicine (IOM) studies. We found a 60.6 percent agreement in the primary diagnosis code among the original coders and our expert coder. The IOM studies documented a 65.2 percent agreement on the principal diagnosis code, in 1977, and a 63.4 percent agreement on the principal diagnosis code of the records analyzed in 1980. Thus, in all three studies there was approximately a 2/3's agreement in the coding of the medical record.
Even among the expert coders, there was a 19 percent disagreement on the primary diagnosis code. Since our expert coders were highly qualified, this high rate of disagreement caused OHI to question the reliability of the selection of the primary diagnosis and, thus, the accuracy of coded information.
A study of ICD-9-CM coding in psychiatry concluded:
The question was addressed how well mental health professionals were able to translate diagnostic formulations into ICD-9-CM codes. This was done with three coder groups and under two conditions. It was found that there was insufficient interrater agreement on the ICD-codes in all groups and conditions. This finding then was related to the inadequacies of the ICD-system itself. It was concluded that current mental health statistics that are based on the ICD-9-CM coding system are without scientific value.
A study of ICD-9-CM coding in intensive care concluded:
In a multicenter database designed primarily for epidemiological and cohort studies in ICU patients, the coding of medical diagnoses varied between different observers. This could limit the interpretation and validity of research and epidemiological programs using diagnoses as inclusion criteria.
Since other nations have already switched to ICD-10 or their own national variant of it (none of which has even half as many as 68,000 codes), what has their experience been with ICD-10? Better coding? No.
One study of the reliability of coding with ICD-10 concluded:
The refinement of the ICD-10 accompanied by innumerous coding rules has established a complex environment that leads to significant uncertainties even for experts. Use of coded data for quality management, health care financing, and health care policy requires a remarkable simplification of ICD-10 to receive a valid image of health care reality.
A study from Canada even compared the quality of coding between ICD-9 and ICD-10 and concluded:
The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM.
So then, manual assignment of ~13,000 ICD-9-CM codes in the U.S. and elsewhere, and the manual assignment of ~13,000-30,000 ICD-10 codes (depending on national variant), have not been "effectively managed".
It brings to mind the old adage, those who live in glass houses should not throw stones.
So what of SNOMED-CT? How many disease codes are we looking at?
The July, 2008 version of SNOMED-CT, by contrast, has 63,731 active disease concepts. [1]
SNOMED-CT, therefore, actually has fewer disease codes than ICD-10-CM! It is hard to imagine that manual assignment of SNOMED-CT disease codes could be managed any less effectively than manual assignment of ICD-10-CM disease codes.[2]
Myth: Busted.
[1]Because SNOMED-CT, unlike ICD-10-CM, comes in machine-readable format, these kinds of exact counts are easy to make.
[2]Note that we are not advocating SNOMED-CT for disease coding. And studies conducted thus far have shown lack of reliability in SNOMED-CT disease coding as well.
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