Electronic Health Reporter

Guest post by Jeffrey Rose, M.D., CMIO, TriZetto Corporation.

With a flourish of congressional shenanigans lifted almost word for word from the teleplay of Netflix’s House of Cards, the HHS-mandated 2014 transition to use of the ICD-10 coding classification was brought to a screeching one year “delay.” We are left, once again, with “at least” another year of collecting healthcare information via ICD-9, an awful but omnipresent healthcare coding system. And more concerning, we are left with the impression that diligent and expensive work to comply with rules in a host of other areas, such as meaningful use of electronic health records, could become abruptly irrelevant. The result of the delay is that not only do we have a significant number of long-time objectors to the change to ICD-10, but they are also joined by a surge of rightfully angry and dubious ‘compliers’ who put in time and investment dollars to meet the deadline.  But there are also some additional considerations given the amount of time that has passed as we prepare to make the trip.

Is this trip still worth the aggravation and expense?

The major underlying rationale of moving to ICD-10 remains laudable: to provide greater clarity to our understanding of healthcare practices through the use of better industry standard, diagnosis codes.  With more granular, relevant and precise core codes at the foundation, medical quality and effectiveness studies utilizing these codes for analysis and program development were to have benefitted dramatically.

Given that our desire to advance healthcare value and improve outcomes through accountable care practices (‘fee-for-value’) we must acknowledge our dependence on much better information collection for analysis than is possible from ICD-9[1]. Significant questions remain however, as to whether the move to ICD-10, using codes predominantly still entrenched to support fee-for-service billing processes will get us where we want to go.  While we can hope the enhanced and detailed nature of ICD-10 might yield greater insight into the real value of our activities, this remains a particularly frail hope in light of the way we use the codes as revenue cycle fuel.

If we are still making the trip to Betterdataland, is there some other flight I can take, or can I go through another city airport?

Enter Flight ICD-11, which is scheduled for release by the World Health Organization in 2017.  ICD-11 is reputedly structured in a way that is much more rigorous and conducive to obtaining good clinical information than ICD-10. It is closer to a true common medical terminology that could be leveraged beyond what is collected to justify reimbursement. The ICD-11 structure is to be better aligned with accepted clinical reference terminology sets, like SNOMED², which has been ‘mandated’ to replace even ICD-10 codes for use in recording specific data elements in electronic health records as part of the HITECH Act and requirements for Meaningful Use certification and rewards. The change in the structure and nature of ICD-11 makes it an entirely distinct from ICD-10, and potentially far more useful for clinical data accuracy linkage to other medical terminology coding systems.  So after all these delays in ICD-10, should we reconsider our trip altogether?

Do I still really want to go to the same destination?

Well weary traveler, the delay in the flight gives us time to rethink our trip altogether. We could consider roaming to clinical Betterdataland (SNOMED and others) and skip the stop-over at ICD-10 , recognizing that this will require us to limp along with ICD-9, and potentially be penalized if the mandate actually does hit in 2015. We can stay the ‘mandated’ course despite the delay, and use ICD-10 to do what ICD-9 already does fairly well (billing), thereby at least salvaging the preparation expenditures made in the last year, which would be wise given that the mandate still exist, however precariously. In this case we can clearly use the delay to prepare even more completely for the deadline, bringing along stragglers (nearly 50 percent of healthcare stakeholders who were clearly not progressing satisfactorily for the 2014 date).

In all likelihood, people are not going to start using ICD-10 this year, for which half of the industry prepared. Why?

• First, the transition has lost momentum and even garnered sudden death style uncertainty, thanks to Congress.

• Second, the delay won’t be terribly detrimental to the industry immediately.

• Third, those players who had money in their budgets to complete remediation based on the now delayed cutover have a windfall to spend on other things of higher importance to their businesses.

• Fourth, the delay will stimulate informatics and policy leaders to again reconsider the merits of moving to ICD-10, with alternatives (ICD-11, SNOMED, etc.) becoming more likely and proximate than they were several years ago.

• Fifth, for the industry to cope with this change, everyone has to work together, across geography, care domains and payer and provider roles. Anything else will create more information and industry silos and stimulate a huge ‘advance to the rear’ situation.

Is there actually any major upside to making this trip?

The biggest potential reward of this massive trans-industry change, which also constitutes its biggest risk, is the high level of collaboration required among stakeholder groups: payers and providers and HIT vendors required for success.  Insurers, clearinghouses and caregivers will all have to work together to make sure end-to-end processes work, and observers and data consumers at large have to make sure that their finance, analytics and reporting applications all run appropriately across the continuum with the new data elements.

In the meantime, the debate on next steps continues. I welcome your thoughts.