Editor's Note: The Year That Was
By Lee DeOrio
For The Record
Vol. 29 No. 12 P. 3
Are you a fan of random cut-off points? You see this technique employed often in the sports world. For example, Team A has won six of its last eight games, or Joe Slugger has reached base in seven of his last 10 plate appearances. These sorts of statistics have their place but also can be a bit deceiving in that the user cherry-picks the sample size to fit the narrative.
In any event, what's a calendar year but a selection of dates with convenient start and end points? Maybe if you moved back the year's start date two weeks, it would have been a better year. Nevertheless, the "year" serves as a ready-made time frame for making judgments about whether these were good or bad times. For the health care industry, 2017 marked the debut of the Trump administration, which practically guaranteed there would be fireworks in one form or another.
Much of the debate, however, centered around the Affordable Care Act, a piece of legislation with nebulous ties to the HIM and HIT fields. The short-lived tenure of Tom Price, MD, as head of Health and Human Services raised an eyebrow for sure, but it was met with more of a shrug on the HIM side of things.
To learn what mattered most to HIM professionals in 2017, I sought the opinions of For The Record's contributing editors and editorial advisory board members.
Deborah Kohn, MPH, RHIA, CPHIMS, FACHE, CIP: "HIM appears to be moving closer and closer to revenue cycle management (RCM) and reporting to CFOs, given the historic success of implementing ICD-10, the growing involvement of HIM in clinical documentation improvement, and the continuing confusion and complexity of the US health care reimbursement and insurance industries.
"Meanwhile, HIM appears to be moving farther and farther away from health information technology and informatics (HITI) and reporting to CIOs and chief technology officers given the historic success of implementing EHR systems in almost all US hospitals and most physician offices. Despite the fact that HIM skills and knowledge are well suited to HITI and its current disciplines such as data analytics, information governance, and EHR optimization compared with RCM, HIM appears to be far less involved, especially in HITI discipline leadership roles."
Judy Sturgeon, CCS, CCDS: "In general, my increasing concern about the profession of clinical coding involves what seems to be an escalating priority for speed and automation at the cost of coding accuracy and data quality. This isn't my personal observation; it has been observed and discussed at length by some of us old silverbacks in the profession.
"Coders are in demand so it appears that some (many?) facilities are lowering their requirements for coding professionals, and at the same time coding credentials are getting easier to attain. It's nice that coding tests can now be done online with multiple-choice answers and equal focus on inpatient and outpatient rules, but when does any complex patient chart come with multiple-choice options for coding in the real world?
"Computer-assisted coding is nifty, but at what price? When the pressure is speed, the coder may be inclined to just accept codes that are offered by the product instead of validating the suggestions. This is especially true if the set-up of the product has also focused on speed rather than accuracy. The old adage of 'garbage in, garbage out' is still true today. If the coding department is also forgoing accuracy audits on a regular schedule (looking at speed instead of accuracy? Maybe they don't want to know what the results are?) then there is a double-down on risk of significant payment loss should the Centers for Medicare & Medicaid Services (CMS) or other auditors decide to pull a significant audit. And audits seem to increasing by leaps and bounds, not only by Medicare but also by everybody who ever pays any patient care provider. How can accuracy not be considered a serious priority?
"Aside from generalities and looking instead at coding specifics, I was really pleased to see the some of the updated coding directions that affect calendar year 2017. From the 2017 official coding guidelines, effective from October 2016 through September 2017, some of the most significant changes in basic coding rules that stand out to me are the following:
"• I.A.12.a. has an exception to the Excludes1 definition that allows a code that is usually assigned elsewhere to have dual coding (you can use both codes) when both conditions exist and are unrelated to each other. An example of the normal exclusion is to code both a congenital and a noncongenital code for the same condition. A referenced exception would be 'sleep-related teeth grinding' with concurrent 'psycogenic dysmenorrhea' despite an Excludes1 note under F45.8 because these are two physically unrelated conditions that can coexist in the patient.
"• In the same section and chapter, at #15, there is added instruction on how to proceed when the index includes a subterm 'with,' as is often the case with conditions in a diabetic or hypertensive patient.
"• In the same section and chapter under #19, an addition caused more than its share of confusion. 'The assignment of a diagnosis code is based on the provider's diagnostic statement that a condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.' Oh no! If the physician just drops in a diagnosis without any clinical information to support it, do we just report the code and no longer query for supporting documentation? (Think 'urinary tract infection' with no labs or symptoms documented.) If the chart is full of contradictory information can we no longer query, and just have to code the last documented diagnosis? (Think 'final diagnosis of lymphadenopathy when the pathology report documents malignancy.) Is a career in clinical documentation improvement doomed?
"Not to worry, a later Coding Clinic publication cleared this up, stating that it just means the coder can't decide to report—or not report—a code based on their own interpretation of clinical information in comparison with a documented diagnoses. Queries are not only allowed, they are encouraged whenever appropriate.
"• I.B.14 has updated its directions for coding body mass index (BMI). This guideline no longer states, 'As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis.' That means there is no longer conflicting directions from the 3rd Quarter 2011 Coding Clinic pages 3–4 that state, 'Individuals who are overweight, obese, or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the BMI code meets the requirement for clinical significance when obesity is documented.'
"• I.C.9.a adds another critical reporting rule: the classification presumes a causal relationship between hypertension and heart involvement as well as between hypertension and kidney involvement. 'These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.' This is a reversal of all prior years' directions for not presuming a relationship between heart disease and hypertension unless specified otherwise.
"My concern is that reporting of patient health statistics from October 2016 forward will make it seem like there's a sudden terrible increase in the effects of hypertension on heart patients. The statistics may be greatly increased, but it doesn't reflect a true change in patient morbidity or mortality—it's due in great part to a reversal of reporting rules.
"• I.C.12.a.6 throws another monkey wrench in the works, and this time it affects reporting of a common diagnosis that affects quality reporting. Prior to this publication, a decubitus ulcer that worsened after admission was coded only to the ulcer stage present on admission. From here forward, the ulcer must be coded twice—once at the initial stage and once at the final stage. Prior to this, a stage 1 ulcer that worsened to stage 3 would only be coded to the lesser stage and would not trigger a quality concern and a possible lowering of the Medicare severity diagnosis-related group payment as a significant hospital-acquired condition.
"It seems right that the final stage of the ulcer is truly the most appropriate to report because it can really be a quality of care issue, but now the statistics will imply that there were multiple ulcers rather than a single one that worsened. There must be a way to correctly report hospital-acquired conditions without incorrectly reporting the number of decubitus ulcers from which patients suffer.
"• I.C.16.b.1 corrects a vacuum that was created when ICD-10-CM was implemented. For a year, there was no way to correctly report a newborn with a condition that was suspected but eventually ruled out. For that period of time (fiscal year 2016) it was possible to only code the maternal condition as (suspected to be) affecting the newborn. This results in a busload of newborns being reported with seeming to have been affected by a maternal infectious and parasitic disease instead of with 'suspected infection, ruled out.' The new codes and Coding Clinic instructions restored the coding and reporting of these babies to the prior true status for a newborn that was eventually found to not have a suspected problem.
"The October 2017 Official Guidelines don't stand out as much to me as do the many updated and added procedure codes. I was getting really tired of Coding Clinic telling us how to code procedures incorrectly because there wasn't an option in ICD-10-PCS that would allow them to be reported with the true approach, or in the correct body part. After all of the hype that ICD-10-PCS would enable wonderfully detailed coding, it was a relief to see that many of the failures had been addressed from October 1, 2017, and forward.
"Coding Clinic publications in 2017 always had good info, but one in particular has provided another much-needed clarification—this time on whether cellulitis in a diabetic patient is presumed to be a 'diabetic skin complication' and that any nonspecific code including the term 'NEC' is an exception to the general directions for coding diabetes 'with' index entries that cover broad categories of conditions (4th Quarter 2017, page 100–101)."
Stanley Nachimson: "I see 2017 as the year of a reset in HIT. With the passage of the 21st Century Cures Act late last year, there have been significant shifts in oversight and priorities. The new administration also set some new priorities. And providers are questioning the current value of EHRs and quality measures. The issues of provider burnout, too many clicks, and lack of focus on patients are coming to the forefront as we question the pace and benefit of HIT adoption.
"The Office of the National Coordinator for Health Information Technology (ONC) set some new priorities for themselves regarding HIT. They said they are shifting their focus to interoperability and usability of EHRs. There is also a recognition on ONC's part that HIT consists of more than just EHRs. In their latest standards inventory advisory, they added administrative transactions (the HIPAA transactions of claims, eligibility, remittance, and claims status) to the inventory, recognizing that administrative data are also being exchanged. In my view, this is a big step for ONC, as they have had a laser focus on clinical data only.
"Meanwhile, the new CMS view was that providers needed much more flexibility in meeting requirements, so that in 2017 providers were given the opportunity to ease into the Merit-Based Incentive Payments System (MIPS). Avoiding a penalty took only a little bit of reporting on one or two measures. Gaining some bonus was also relatively easy. For 2018 the bars were raised a little higher, but not much. And for both hospital meaningful use, and MIPS reporting, either 2014 certified EHRs or 2015 certified EHRs were accepted, recognizing the lack of vendor progress in meeting 2015 certification requirements.
"CMS is recognizing that current quality measures focus too much on process and not enough on outcome. They have started a 'Meaningful Measures' initiative, working with the industry to develop and adopt better measures of quality. In an example of why quality measures need to be questioned, a new JAMA study found that as hospitals reduced readmission rates for heart failure patients as part of the CMS readmissions program, mortality rates for those patients rose. The findings are in line with previous research that found mortality rates have increased for heart failure patients since the start of the CMS readmissions program.
"Security remains a big issue in the industry, with lots more breaches reported in health plans, providers, and vendors. Efforts are being undertaken at the federal level, but the need for investments and training in IT security is just now being recognized. Smaller providers continue to be especially vulnerable due to lack of expertise and capital for full security protection. The industry clearly needs to take a step back and determine optimum approaches to HIT security."
Susan Lucci, RHIA, CHPS, CHDS, AHDI-F: "It would be difficult to reflect on 2017 without a mention of the cybercriminal activities. There have been several this year that have left a significant mark on some vulnerabilities that were not addressed despite the urgings of those in the privacy and security sector. Conducting annual comprehensive risk analyses on all systems, programs, and assets has been required since 2013. What's more, these risk analyses had to be conducted and provided to qualify for meaningful use incentive dollars.
"The first large global attack came through in the WannaCry ransomware attack in May; as you may recall, this shut down the United Kingdom's National Health Service and the attack spread so rapidly that estimates said that more than 300,000 computers all over the world were affected. Then in late June, the NotPetya cyberattack was launched and hit the Ukraine, Europe, and beyond. Health care organizations in Pennsylvania, Merck Pharmaceuticals, and Nuance were hit hard. NotPetya was unlike traditional ransomware in that it was a rapidly spreading worm designed to search and destroy, rather than encrypt data for ransom. In fact, there was no one to pay a ransom to, and no decrypt file to gain. Nuance, as one of the largest providers of medical transcription services in the United States, was crippled for weeks with providers unable to dictate, and health care documentation professionals unable to work.
"What can we take away from 2017 on the security front? Last year should be viewed as a large flashing warning sign to all who house or provide access to [protected health information] as we head into 2018. We must do more to ensure vulnerabilities are being addressed as a priority. The bad guys have no incentive to stop their relentless assaults intended to gain access to patient data, and until they meet up with a fortress they cannot break through, they will continue."
Gail I. Smith, MA, RHIA, CCS-P: "The coding profession seems to be struggling, and I believe pieces of the foundation are missing, and we are not moving forward. I long for an infrastructure that includes 'schools of excellence' for coding that incorporate a strong clinical foundation, not just 'finding a number' and getting paid. Can we as a profession declare where to get the best clinical coding education in the country? Can we even define it? We seem to be debating the definition of information governance but not giving any energy to the clinical coding profession. There are rumors that coding is going away, and I would love to debate that topic. There are many codes that can be assigned by the computer that require no human intervention, but will clinical coding decision making really go away? I do not think so.
"In this country, data are vital to support decision making. The hidden mysteries within the health care data are based on coded data. Who are the experts defining, organizing, and improving these coded data?
"If we continue on this path and do not support education, research, and resources for the clinical coding field, it will transition to another professional entity and the HIM world can honestly say that coding did go away … but we drove it away."
Sandra Nunn, MA, RHIA, CHP: "I was surprised and disappointed this year when I realized that little growth had been made toward health information exchange and interoperability and that another decade might go by before health care information might be exchanged readily among health care organizations.
"In pursuit of a Certification in Health Informatics, I was happy the courses were easy to master and would lead to better career opportunities for HIM students.
"Along with other Americans, HIM professionals attending AHIMA's House of Delegates, particularly coders, are feeling the impact of outsourcing and automation of coding functions (computer-assisted coding) in terms of lack of job security.
"I remain impressed with AHIMA's investment in information governance despite low industry penetration—this is a good long-term strategy. I share the speculation regarding AHIMA shifts in leadership in hopes to reengage members and increase membership from younger graduates.
"I could only agree with HIM leaders as they push membership toward the need to achieve more education and higher degrees.
"It's hopeful and exciting that HIM graduates are pioneering their way into new types of work and professions."
Dale Kivi, MBA: I believe the greatest issue for the HIM community throughout 2017 was a reckoning on vendor accountability. Triggered by the catastrophic cyber event with Nuance, the industry was forced to create workarounds and/or implement alternate solutions as the front end of the clinical documentation process for literally thousands of hospitals and clinic practices disappeared off the face of the earth. Nuance did their best to keep clients and employees informed on the situation and return to normal operations as quickly as possible while ensuring the IT infrastructures of their clients would not have to suffer the same fate.
"Across the board, vendor and provider group teams earned their keep in crisis mode for about two months. Although shoulda, woulda, coulda arguments are debatable (and currently being investigated by Congress), the bottom line is only one company in the vast HIM and HIT vendor community was affected. Had it been a smaller vendor, I expect the event would simply have been seen as a warning to improve protection against such threats. Given the size and resources of a firm the size of Nuance, however, one has to wonder who is truly being held accountable and what price should be paid.
"Word on the street is the vast majority of their clients eventually went back, some motivated by threatened legal action from the very firm that let them down. They lost a lot of operating revenue, paid a pretty penny to recreate their infrastructure from scratch, and experienced a dramatic downfall in their stock value. Thousands of their employees lost their jobs, both domestically and abroad. There is no question they paid a high price, but so did the clients who were left high and dry.
"As we enter 2018 and beyond, the question is how will the industry respond. Many clients have already circled the expiration dates of their current contracts. Others are reviewing contract details to ensure they have the flexibility to hedge their bets with multiple vendors moving forward. Some are looking at ways to completely eliminate traditional transcription service and technology from their workflow. The only certainty is that this is far from over. During the crisis and immediately afterward, clients had no choice but to react and minimize their own damages. In the future, they will have no choice but to protect themselves. Those responsible for choosing vendors will not get another free pass from their employers. Someone has to be held accountable."