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April 2014

It is time for the U.S. to begin implementing health IT smartly

From a national policy perspective, ICD-11 is not found anywhere on the U.S. dial.   Not even a preliminary roadmap to ICD-11 has been proposed.   I believe this to be a serious risk to our nation’s health IT planning efforts, and this risk has been inherent to U.S. health IT planning for decades.   The recent ICD-10 delay magnifies this strategic flaw.   It is time for CMS to take a deep breath, re-evaluate our national strategy, address the unmitigated strategic risks and determine whether any mid-course corrections are needed before deciding on the new ICD-10 implementation date.  It is time for the U.S. to begin implementing health IT smartly.  

What I see right now is the U.S. planning to achieve a short-term tactical goal of getting off antiquated ICD-9 while the rest of the world is focusing on the long-term strategic goal of developing and adopting the new-century ICD-11.   Unless we take action now, we are destined to be in the same predicament in the 2020s when we will be struggling to get off of last century’s ICD-10.   

But the stakes will be much higher in the 2020s.  

Most physicians and hospitals will be using EHRs, health information exchange will be flourishing, SNOMED-CT will be the common vocabulary used by clinicians and big data analysis will be... well, big.  We will be stuck, though, with an ICD-10 taxonomy that was developed before the Internet came into common use.   We will be clamoring for ICD-11 because it was developed in alignment with SNOMED and for other reasons I and others have previously described.  Delays will likely be encountered.  And we will probably be amnesic about how we got into such a predicament.  

To avoid this we need a U.S. roadmap to ICD-11 before deciding when to implement ICD-10.   We need to determine our long-term goals and then align our short-term tactical plans to those goals.   What if ICD-10 is delayed another year?   Would it then be time to leapfrog to ICD-11?    What if the delay is 2 years?   How about 3 years?   Or maybe to meet our long-term goals it is actually time to leapfrog now.   But without establishing long-term goals and developing a proposed roadmap to ICD-11,  we cannot really make an informed decision. 

Yes, we have to get off ICD-9, but not at any and all costs.   I want the U.S. to change health IT planning efforts from one that risks derailment from ostrich-style decisions to one that smartly develops long-term strategic goals and aligns them to tactical plans.  I want us to be a country that leads the world in the use of health IT to improve quality of care and one that smartly plans to optimize health IT use each decade.

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MM


Ask Not What ICD-10 Can Do For Healthcare, Ask What Healthcare Can Do With SNOMED and ICD-11

ICD-10 is so “last century”.    The United States did not adopt ICD-10 twenty years ago when the standard was first developed.    The current version of ICD-10 that the United States is designated to adopt is based primarily on the international version of ICD-10 that the World Health Organization (WHO) published in 1990.    The international version was drafted by committees that began their work over thirty years ago in 1982 (see 2nd Edition of ICD-10 by WHO).    In other words, our version of ICD-10 is based on work done before use of the rich information space called the Internet became common and before the human genome was mapped.

ICD-11 is “this century”.    According to an article in Healthcare Financing News, Christopher Chute who is one of the leading informatics experts and a Chairman of an ICD-11 Revision Steering Group at the World Health Organization stated:

“ICD-11 will be significantly more sophisticated, both from a computer science perspective and from a medical content and description perspective…. Each rubric in ICD-11 will have a fairly rich information space and metadata around it. It will have an English language definition, it will have logical linkages with attributes to SNOMED, it will have applicable genomic information and underpinnings linked to HUGO, human genome standard representations. ICD-10, as a point of contrast, provides a title, a string, a number, inclusion terms and an index. No definitions. No linkages because it was created before the Internet, let alone the semantic web. No rich information space.”

ICD-x codes are used by non-clinicians for important administrative and financial purposes.    SNOMED-CT, on the other hand, is what physicians will actually use to communicate information about patients in their electronic health records (EHRs).    In fact, physicians must use SNOMED vocabulary in their EHRs, not ICD-x codes, for their problem lists in order to achieve Stage 2 Meaningful Use for incentive payments and to avoid Medicare penalties in the future.    Unlike ICD-10, ICD-11 is based on SNOMED.  And SNOMED includes over 311,000 concepts with unique meanings, making it more granular than ICD-10 or ICD-11.  

One way to think about the relationship is that SNOMED is the input and ICD-x is the output.  SNOMED is used by clinicians to input clinical information into the EHR at a high level of detail.  ICD-10 and ICD-11 aggregate that data into less detailed classifications that are more useful for output purposes such as quality reporting.    They really cannot replace each other.   But we could and should require EHRs to map in the background the SNOMED codes used by physicians into the ICD-x codes used by others.    No need to engage physicians in ICD-x debates or to learn new vocabularies each time WHO does their thing with the U.S. traditionally following way behind.

So what the HIT are we thinking?    Do we really believe that healthcare quality will be significantly improved based on ICD-10 that was developed out of work done over 30 years ago before the Internet was commonly used and before human genome coding was completed?    Or do we believe that we need to adopt ICD-11 for output purposes and to use SNOMED–CT in EHRs for input purposes in order to move the quality needle in the right direction?

I for one believe that we need to get to ICD-11 as soon as possible.     And I believe we should cut the umbilical cord to ICD-10 right now because:

  1. There is currently no information showing that a conversion to ICD-10 is required before ICD-11.
  2. It is intuitively obvious that the costs of going to ICD-11 directly from ICD-9 would be less than incurring the remaining costs of implementing ICD-10 in 2015 (or later) and then implementing ICD-11 sometime thereafter.    And that includes the sunken ICD-10 costs.    If you believe that this is an outrageous assumption, then prove it to be untrue.    Show the comparative costs of both pathways.    But don’t just comment or blog that it’s ridiculous without providing some kind of evidence.     Sometimes it’s wisest to go with intuition.
  3. The ICD-10 implementation has been so painful that it is unlikely the industry will have the stomach to move on to ICD-11 within a decade.    This will result in an excessively long delay to ICD-11 and an excessive period of time using a classification system from the previous century.
  4. There is consensus among leading informatics experts that ICD-11 is superior to ICD-10

 

Matt Murray, MD