Hospitals: ICD-10 Switch Means the EHR Must Wait

The American Hospital Association sent a letter (PDF) to the Healthcare Information Technology (HIT) Policy Committee urging a delay in implementing stage 2 of Meaningful Use criteria for electronic medical records (EMRs), in large part because hospitals are otherwise busy in switching to ICD-10-CM.

Both ICD-10-CM and EMR adoption are unfunded mandates of the federal government, although there are incentives for EMR adoption (non-adoption will eventually result in penalties that come in the form of reduced reimbursements per service). To qualify for incentives for EMR adoption, hospitals must demonstrate "meaningful use", and the federal government has set criteria for it. However, the criteria will become more stringent over time. Currently hospitals must meet "Stage 1" criteria.

The letter is about when "Stage 2" meaningful-use criteria should go into effect. Hospitals are saying that the government should delay stage 2 criteria, because the burden of switching to ICD-10-CM is too high.

As we reported here, hospitals previously asked the government to back off on meaningful use because of the switch to ICD-10-CM.

Of course, we think the EMR is more important, and that ICD-10-CM should take the back seat. Nevertheless, it illustrates one significant effect of the ICD-10-CM switch: delayed adoption of EMRs.

ICD-10 or Meaningful Use? Between a rock and a hard place.

The HIT Policy Steering Committee is debating whether delaying stage 2 of meaningful use would allow healthcare providers more time and resources to negotiate succesfully the switch to ICD-10 (or more precisely, ICD-10-CM and ICD-10-PCS).

The conflict between electronic medical record (EMR) adoption and the switch to ICD-10-CM first surfaced almost immediately after passage of the HITECH Act that incentivizes EMR adoptoin, and is highlighted by a letter from the American Hospital Association and a letter from numerous doctors' organizations.

Despite our prediction that the ICD-10-CM switch would pull resources from meeting MU, it turns out that meeting MU is taking resources from the ICD-10-CM switch.

Now, the HIT Policy Steering Committee is starting to recognize that resource-constrained healthcare providers will have severe difficulties doing both. However, it should have realized this problem much sooner since they certainly were privy to the letters sent above, dated in June, 2009. Almost two years ago!

Now they propose to delay MU "stage 2" criteria, to allow resource-constrained providers to meet the ICD-10-CM mandate.

Why not propose instead that the switch to ICD-10-CM be postponed or even canceled?

Granted, they can only control directly the timing of stage 2 MU, but surely the members of the Steering Committee have some influence with decision makers in Health and Human Services?

Doctors: Regulatory burden crowds out health care reform

In a letter to Donald Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services, the American Medical Association lists the regulations that have been and continue to be most burdensome to physicians.

I will let the letter speak for itself (emphasis exactly as in original). Note that ACA = Affordable Care Act, the major healthcare reform bill enacted into law in 2010.

The human and technological investments needed to participate in quality incentives are competing for physician time and resources needed to move to an enormous new set of diagnosis codes in ICD-10. The struggle to keep up leaves little time to get engaged in the practice redesign and payment and delivery reforms envisioned in the ACA and detracts from patient care just as the ACA is promising access to millions of uninsured Americans. We strongly urge the Administration and CMS to carefully consider the impact the collision of these compliance deadlines will have on physicians, patients and the ACA’s promise of better care for more people.

The Breathtaking Scope of ICD-10-CM Revisions for 2011

The Centers for Medicare and Medicaid Services just released a 2011 version of ICD-10-CM. A quick look at the "ICD-10-CM 2010 to 2011 Addenda" reveals a breathtaking scope of change.

First, the "Addenda" document (misnamed, since it also includes things removed and edited, not just added) for the tabular index totals 185 pages in a file nearly 1MB in size. Second, the changes span every chapter of ICD-10-CM.

Worse still, is that numerous codes have undergone a change in meaning, something decried by experts in medical informatics over 16 years ago.

Here is an example:

C64.1 Malignant neoplasm of right kidney, except renal pelvis

is now:

C64.1 Malignant neoplasm of left kidney, except renal pelvis

The update also deletes codes, which also militates against best practices in medical terminology management. Deleted codes include C64.0, C65.0, C66.0.

Anyone trying to update software applications that take advantage of particular codes for logic-based processing will surely have to review all 185 pages very carefully to esnure that their logic remains consistent. DRGs will have to be reviewed as well.

These substantial changes just 1.5 years prior to the deadline to switch will increase the cost and complexity of the switch. Another unwelcome development in the long, sad saga of ICD-10-CM.

Absurd arguments for ICD-10-CM

Sometimes, the arguments in favor of ICD-10-CM border on the absurd. In the January, 2011 issue of Healthcare IT News, the increased "specificity" of ICD-10-CM is highlighted as improving cost savings and disease management. What evidence are we given? The following list of codes:

I'm sure that there are hundreds of billions of dollars to be saved in the health care system, now that we can only code dolphin and sea lion bites better.

Dr. Joel Diamond, in his Health Interoperability Blog, documents similarly absurd arguments here. One proponent of ICD-10-CM said we'd be better off because we would be able to document not just "sports injury", but also whether the injured party was struck by a basketball, baseball, or football.

Busy clinicians trying to take care of sick patients are the ones we will rely on to code this additional specificity, however. Do we really want to distract them from patient care to find the code for dolphin vs. sea lion bites, or strikings by basketball vs. baseball? Is this really the best use of six-figure talent?

The cost of switching to ICD-10-CM has been underestimated: Proof.

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.

Doctors spending on EMRs instead of ICD-10-CM switch

As I noted in a previous post, doctors have insufficient resources to both adopt electronic medical records and switch to ICD-10-CM.

As this story indicates, doctors have been focusing resources on meeting the federal government's "meaningful use" criteria for EMRs at the expense of the switch to ICD-10-CM. Specifically, two thirds of physicians responding to a survey reported spending resources on "meaningful use" in favor of ICD-10-CM.

Of course, in my post, I said that the switch would slow down meeting "meaningful use", but it appears that the converse is happening, and that "meaningful use" is slowing down the switch.

Regardless, the switch ought to be deferred to allow physicians to meet "meaningful use".