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December 6, 2010

The Connection Between ICD-10 and Meaningful Use
By Robert N. Mitchell
For The Record
Vol. 22 No. 22 P. 20

Should the conversion to ICD-10 be included in the meaningful use requirements? It’s too late for phase 1, but the code set could very well be a factor down the road.

In the long run, perhaps it would have made sense for the authors of the meaningful use requirements to include stipulations about ICD-10 conversion. How practical such a strategy would have been is open to debate. Now that healthcare organizations are in the midst of targeting meaningful use goals and transitioning to ICD-10, it’s easy to understand why it will be difficult to accomplish both in relatively the same time period. But if they were somehow connected, perhaps the task would have been less strenuous.

ICD-9, long rumored to be headed for retirement in the United States, will finally be laid to rest by 2013, replaced by ICD-10, a more robust cousin that dives into more detail in an effort to garner discrete data with the hope of improving care processes.

Regardless of whether it’s actually part of the criteria, the information gathered from ICD-10 patient encounters could be useful in a meaningful use environment.

CodeRyte CEO Andy Kapit says there’s definitely a relationship between the two initiatives. “The federal government set a low bar in order to make technology ‘meaningful.’ ICD-10’s premise is that we are going to get granular information that will improve healthcare at the public and individual level. Isn’t that truly meaningful then? The better the quality, the better decisions one makes,” he says.

It raises the question about whether ICD-10 will be used to capture health information or will be like ICD-9, which drives reimbursements. In that case, is it really meaningful information that’s being captured?

“We have many conversations with hospitals about their unique experiences, and most of the hospital IT systems can only accept three or four ICD codes,” Kapit says. “So if it’s true that 80% of the nation’s costs are being driven by people with four or more chronic conditions—if they are going into the hospital for an inpatient stay or to an emergency department—then that diagnosis code will be meaningful and important to collect. For example, [if] somebody goes in with a broken ankle, that’s not a big deal to public health. But if it can pinpoint specifics on the body, such as right side of the left ankle, then that’s getting to a much more granular level than we currently have.”

The adage “garbage in, garbage out” applies to healthcare data. If the goal is to capture rich data that can enhance decision making, which in turn can lead to more efficient and more appropriate care, then the initial data must be of the highest quality. “By definition, anything that allows for the capture of more accessible and actionable information is meaningful then, correct?” Kapit says.

“With the broken ankle example, ICD-10 wants to know the kind of break, the type of bone that was broken, and whether it’s an initial visit or follow-up. It’ll want to know which side of the body it’s on,” Kapit explains. “And all of that’s built into the code, so we’re going to know what’s happening because we are going to understand [it] at a much more granular level. We can look at what is leading to a disease: Is it genetic? Is it environmental? This is really important. The U.S., which is supposed to be a visionary country, is about 20 years behind other countries. It’s an investment we have to make because it will improve the efficiency of care over the long term.”

Improved Diagnosis
Mansoor Khan, CEO of DiagnosisONE, echoes Kapit’s thoughts in that the real benefit of ICD-10 is in allowing both billing and care to be described and managed at a more granular level. “While most of the discussion around ICD-10 has been around administrative processes, the real benefit will be realized in improved quality of care through the availability of more granular information for the implementation of robust, patient-specific clinical decision support,” he says.

Rajiv Sabharwal, chief solutions architect for healthcare and life sciences at Infosys Technologies, says the use of ICD-10 demonstrates how coding can help boost clinical diagnoses. “The ICD-10 codes are much more granular. Do you have a pain here? Do you have a shooting sensation there? You can get to the proper code,” he says. “If you get the code set up front at the time of admittance, you can have monitoring systems that send out alerts based on the codes. For example, after 25 minutes have passed and no orders have been received in the pharmacy for aspirin for a patient who has a chest pain that is part of a list where aspirin is required, the system would alert someone. The more granular you are, the better the chances are that you will code accurately and be able to set up a proactive mechanism to manage the requirements for meaningful use.”

The benefits of ICD-10 implementation extend into other hot-button issues currently making headlines. “What is the purpose behind all the healthcare reform initiatives? Improve the quality of care and reduce the cost of care,” Sabharwal says. “Now to improve the quality of care, the more the granularity of the data, the more a doctor could deduce and the better the diagnosis is.”

Not only will richer data give healthcare organizations a leg up when it comes to meeting meaningful use goals, it will also have a long-term economic effect. “To reduce the cost of care, the more granular the information regarding the procedure is, the better are the chances for more accurate assignment of cost categories and improved payment structure,” Sabharwal says. “Today I get a procedure and when I send the claim to the payer, the payer doesn’t have the full details on the procedure. The payer does not know whether the length of stay was justified for that procedure. It’s an average length of stay, they don’t know what type of equipment was used, etc. They have to pay.”

Implementation Strategies
Erica Drazen, managing partner of emerging practice at CSC, says it makes sense to tackle ICD-10 and meaningful use projects at the same time for any new applications a healthcare organization is building. “The redo is complicated because staffing is short with so much to do. Practically speaking, it will be a ‘just-in-time’ redo,” she says.

For healthcare organizations building from the status quo, the plan of attack must be hurried but not harried. “We try to make our clients aware and start working on assessments and building a plan that fits where they are on the rest of their journey,” Drazen says. “The timing matters because of how thinly the resources are stretched, and they need to make realistic plans, changing things and sliding things out later. Realistically, most providers are going to have to use a staged methodology to achieve regulatory compliance at a minimum.”

ICD-10 would have been included in meaningful use only through standards requirements, Drazen says. “And to require everyone to be at ICD-10 by 2011 to qualify for meaningful use incentives would have been very disruptive. Certainly, there’s nothing in the standards that precludes an organization from adopting ICD-10 sooner because you can use a more advanced iteration of the standard,” she says.

Whenever the implementation occurs, don’t expect an immediate change in physician behavior, Drazen cautions. “The physician may write a diagnosis and it will be translated by the billing clerks. That’s one workaround that might be used. It’s not by any means meeting the intent of meaningful use nor is it efficient, but it might be a workaround to get the bill out,” she explains.

Sabharwal says providers know ICD-10 and meaningful use are huge undertakings, but it could be shortsighted to view them as separate from one another. “You can possibly merge these two initiatives into a single, slightly larger initiative and achieve them at a lower cost than if you do them separately,” he says.

Making Meaningful Mean Something
Despite ICD-10’s absence from any specific meaningful use criteria, it does play a significant role. “When you think of clinical documentation, care management, and case management, ICD-10 helps evaluate the care and care pathways. ICD-10 is very helpful for organizations,” says Tracey Mayberry, a partner at CSC. “It depends on where the organization is in its timing of implementing those systems to achieve meaningful use whether they will be able to synchronize forward and know that ICD-10 is part of that.”

On the flip side, he says, “If the organization implemented a core clinical documentation in 1998 or 2003, they will have to redo it so they have an appropriate level of documentation to support the coding. Meaningful use is based on the availability of discrete data so as to support automated reporting and analysis.”

Khan says a move to ICD-10 will prove invaluable if meaningful use requirements become more stringent. “Unfortunately for the users of the U.S. healthcare system, meaningful use, at least in stage 1, has been so watered down that the real benefit it might have delivered through the incorporation of robust, patient-specific clinical decision support has been largely lost,” he says. “If we assume, as has been promised, that a robust clinical decision-support capability will be required at some later stage of the meaningful use criteria, then ICD-10 becomes a very important part of the puzzle for care providers. Additionally, if current trends toward accountable care organizations or other risk-bearing mechanisms for providers continue, then we also see a strong need for providers to utilize ICD-10.”

Jonathan Elion, MD, founder of ChartWise Medical Systems, says just because a healthcare organization meets meaningful use criteria doesn’t necessarily mean the technology is making a difference. “I don’t mean this as a criticism of meaningful use because I think it’s a spectacular stimulus to the creation, application, and use of critical technology, but nobody said it had to be good use,” he says.

For example, a hospital will meet many of the criteria if it has 80% of its stakeholder groups performing tasks electronically, Elion says. “If you can get 80% of doctors and nurses to chart progress notes electronically, then you meet that meaningful use criteria. The progress note system may be awful but because it’s electronic, it qualifies as being meaningful. I recognize that you have to start somewhere and to take the first step, but the word ‘meaningful’ is difficult to define,” he says. “The stimulus plan was announced first, then people needed to define what meaningful meant.”

Drazen cites a CSC survey in which the top issue for its healthcare clients was meaningful use. “The second issue was preparing for health reform, with its accountable care organizations and value-based purchasing—all of which is kicking in—and also worrying about their capacity,” she says. “Very much lower on the list was ICD-10 transition. It’s not gotten on the priority list for most organizations.”

Sabharwal says ICD-10 should have been part of meaningful use—and there’s still hope. “It’s still early and it might turn out to be a part of meaningful use because of some of the things we’ve heard,” he says. “As of now, the meaningful use requirements do not seem to have anything to do with ICD-10, but 2015 requirements for electronic health records may not meet certification if you are still using ICD-9. You may have to be using ICD-10 to have an EMR certified. If that becomes the rule rather than the rumblings that we’re hearing, that’s a convergence point.”

Kapit adds, “ICD-10 is an incredibly important, much delayed advancement for our country. If we use it fully and completely, we will, over the long term, improve the population and individual health. It has not been connected with meaningful use, but ICD-10 is one of the most meaningful information changes that we have made in a long time.”

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pa.