Current Affairs

Improved Physician Practice Preparedness To Recover from EMR Downtime and Other Technology Risks is Needed

It should not take 3 weeks to restore an EMR system.  

I was not surprised when one of my colleagues told me his EMR unexpectedly "went down", as there are many threats to hardware and software--wind, fire, water, construction equipment, human error and cyber crimes to name a few.  It was the rest of his story that was so disheartening.  As he recalled the struggles that his group endured for three weeks, his facial expression contorted into what I can best describe as that of "helpless resignation".   The complexities of technology had held him and his group hostage for three weeks.   At the time of our initial discussion he was still in the "grieving" stage, so I felt it to be too early to engage in a healthy discussion about IT risk management.   He needed to vent.   I needed to listen.  

And this story exemplifies what drives me to spend time collaborating with the Texas Medical Association (TMA) and others to raise physician awareness about the safe use of EMRs.   I do not have data, but my gut tells me that the majority of physician practices underestimate how vulnerable they are to EMR threats, especially small physician practices who lack internal IT expertise.  Perhaps the recent rise in ransomware attacks will actually be beneficial.  A ransomware attack on a physician office in South Texas earlier this year has led the TMA to increase communications to physicians about the threat of ransomware and other cyber attacks.    

Until recently the focus of preventive strategies against cyber attacks has been to ensure that the privacy and confidentiality of electronic medical records (EMRs) are maintained.   HIPAA stuff.   And this is understandable since privacy breaches are expensive for a practice to manage, and such breaches have the potential to financially hurt patients if their data is used maliciously.  But ransomware attacks are different because they make a physician's EMR unusable until a ransom is paid (or the EMR is otherwise restored).  Unlike privacy breaches, ransomware attacks are disruptive to the daily operations of the practice.  It is a disruption that impairs the ability to take care of patients who are in the office as well as those who call the office.  At the end of the day the physician is left struggling to take care of patients who are sick without access to information that is really needed.  This is a "new normal" that should brightly illuminate the need for improved disaster recovery preparedness and IT risk management for physician practices.    

There are ways to reduce the threat of ransomware attacks and other health IT risks.  A thorough security risk analysis can identify weaknesses that could be targeted by cyber criminals.  Steps can then be taken to reduce the chances of being victimized.  Establishing a habit of continually identifying and managing these technical risks will further reduce the chances of an EMR shutdown.  

But one of the major obstacles is that physicians generally do not have the knowledge, expertise and time to do this themselves.  Another obstacle is that security risk analyses tools are designed primarily for large healthcare systems and do not translate well onto a small physician practice.  That is why the TMA's ad hoc Health IT Committee is currently collaborating with a vendor, a state agency and one small physician practice to hone down a security risk planning tool into something that would be feasible and effective for small physician practices to adopt.  For now physicians have to rely on consultants or train/hire IT staff to identify and manage technology security risks.

Nevertheless, no system can be 100% "downtime-proofed".  So even if a physician practice adopts best practices for security risk management, they must be prepared for a disaster to strike at any time.  After a disaster strikes, maintaining the ability to effectively care for patients must be the first priority.  I have coined the term, "clinical continuity planning", to characterize this planning.  I base the term on a similar commonly used term, "business continuity planning", which is the plan businesses develop to maintain daily operations during technology downtimes and disasters.  A physician office certainly is a business and should have a business continuity plan to maintain economic viability during disasters.  But the life-and-death nature of patient care is so unique that I believe a clinical continuity plan should be developed by each practice and be considered as the first priority in disaster planning.  Business continuity is integrated with clinical continuity and is also vital to the physician practice, but it should be considered as a lower priority.  In the real world this means that when weaknesses in security and downtime planning are identified, clinical continuity weaknesses should be addressed before business continuity weaknesses are addressed.  
 
The most effective protection against a ransomware attack and other types of "downtime" is to have a complete back up of EMR data and an ability to quickly restore the EMR system.  If the practice can do that, they may not have to pay a ransom, and the impact on patient care can be minimized if the back up and restore tools/processes are effective.  
 
With the rise of ransomware attacks I believe the primary focus of health IT risk management for physician practices should be to ensure an acceptable degree of clinical continuity can be maintained during EMR downtimes.  Secondarily, the practice should understand the tools and processes that are in place to back up and restore the EMR in the event of a disaster.  And to make sure they get tested.    The first time a physician discovers that it will take 3 weeks to restore their EMR should not be after a real disaster strikes.   
 
 
mattmurraycook children's
 mgg
 

Cultural Change at CMS is Needed to Mend Adversarial Relationship With Physicians

CMS has issued a request for information (RFI) and invited comments on the implementation of the Merit-Based Incentive Payment System (MIPS) as introduced in the MACRA legislation that repealed SGR last April.   The legislated "composite performance score" upon which "adjustments" to physician payments will be made under MIPS consists of four categories:  Quality, Resource Use, Clinical Practice Improvement Activities and Meaningful Use of CEHRT.   Comments are being sought on many topics, including certification of EHRs, technology standards, accountability for data integrity, management of "virtual groups"  and, yes, Meaningful Use (MU).

I have three overarching comments:

1.  Adversarial relationship with physicians:  Right now government programs such as MU and PQRS are generally viewed by physicians as requirements only, not as elements of best practices that lead to quality care.  I think it is vital to change this adversarial perception.  This will involve a cultural change at CMS.  Perhaps the most important tactical change to pursue is moving away from rewarding/penalizing the achievement of specific targets, and moving toward innovative programs that reward practices for making incremental improvements in quality care.

2.   Inhibition of Innovation:  Physicians support technology innovations developing in the consumer marketplace that have the potential to improve quality of care and lower healthcare costs.   While government regulations have the potential to catalyze innovations in the consumer marketplace, they also have the potential to inhibit innovation.    Regulations that strive for high-level outcomes are generally more likely to catalyze innovation, while regulations that impose specific limits or require specific actions, mechanisms and processes are more likely to inhibit inhibition.   I believe the Meaningful Use regulations have inhibited innovation--EHR vendors have been scrambling to meet specific requirements imposed by the regulations with no evidence that these requirements would result in higher quality of care or lower costs.    To change this, we need CMS to mindfully develop government regulations that maintain a high-level focus on the achievement of quality care outcomes while avoiding the development of limitations or specific requirements, methods and processes that discourage innovation. 

3.    Fair and ethical use of quality metrics for reimbursement:   The AMA has published guidelines on the Fair and Ethical Use of Quality Metrics.    The guidelines advocate for rewarding physician practices that make incremental improvements in quality care rather than rewarding/penalizing the achievement of specific levels of performance.   Although my opposition to the use of quality metrics to impose financial penalties is aligned with these guidelines, I concede that it is difficult for a value-based model of reimbursement to completely avoid penalties.    My alternative suggestion is for CMS to incorporate tiered levels of "performance achievement" instead of the "all-or-none" requirements put in place for the MU program.  Tiered levels of achievement, with lower levels of achievement designed to avoid certain penalties and higher levels designed to provide additional rewards, will help avoid the "drop-out" rate that the MU program has experienced after Stage 1 as the levels of expected performance were increased.  Many physicians just gave up.  Even though they could achieve all but one of the requirements, that one requirement eliminated the possibility of receiving any credit.  

I  would be interested in hearing your thoughts on the implementation of MIPS by CMS.


Keys to Gain Value from EHR Implementation and Use

Many physicians who use an electronic health record (EHR) are having difficulty realizing value in their investment.   A recent KLAS survey found that more than one out of every four physician practices are so dissatisfied with their EHR that they are considering replacing it.    Although many physician practices have earned a financial award by using an EHR to achieve “meaningful use”,  data is lacking on whether or not such efforts actually improve patient outcomes.  

I believe, anecdotally, that I practice higher quality medicine when using an EHR.    But I am a pediatric emergency medicine physician using a hospital EHR to document patient encounters in a children's hospital's emergency department, not a physician in private practice.  On the other hand, my past experience as a a Chief Medical Information Officer (CMIO) and Chief Information Officer (CIO) for my pediatric healthcare system provided opportunities to visit many private physician offices using a variety of ambulatory EHRs and to visit with many EHR vendors.  I met many physicians  who were happy with their EHRs and see the value.  Others I met were unhappy and see no value in their EHR.  Perhaps my most eye-opening experience came when I visited with a group of unhappy physicians who were using the same EHR as some happy physicians I had met one week earlier.   So what gives?

The answer is simple, but the explanation is complex.  

The simple answer is that the value gained from an EHR is dependent on how effectively it is implemented and used.   When well-implemented and well-used, an EHR provides clinical and financial value.   When poorly-implemented and poorly-used, EHRs detract from patient care and are a financial drain.  

The complex explanation might best be explained using examples.  So, based on my past visits with physicians who use various EHRs and on other personal research, I have created an outline of what I think are the key factors that allow physicians to gain value from their EHR.  I am in the process of writing a series of blogs with case studies to help explain each of these factors.  Stay tuned! 

Keys to Gain Value

 

cook children's

 

Dr. Matt Murray

Cook Children's


Failure to Address Physician ICD-10 Concerns, Misalignment of Federal Health IT Priorities are Strategic Blunders

Texas Representative Ted Poe has introduced H.R. 2126, the Cutting Costly Codes Act of 2015.   This legislation would prohibit the federal government from requiring physician offices to comply with the proposed transition to ICD-10 codes. “The new ICD-10 codes will not make one patient healthier," Representative Poe said.    "What it will do is put an unnecessary strain on the medical community who should be focused on treating patients, not implementing a whole new bureaucratic language.”  He has clearly listened to the Texas Medical Association (TMA) which has consistently advocated for postponement of ICD-10 on behalf of 48,000 physician members.  

I am one of those Texas physicians who is thankful that a congressman has listened to us.  If this bill were passed it would postpone ICD-10 and call for the GAO to study the issue, but it does not propose any solutions.  Although I am in favor of this bill, I agree with the cry of many healthcare stakeholders that we need a solution to move away from the antiquated ICD-9 codes.  It seems likely that a bill that does not propose an alternative solution will have difficulty getting passed.  

I am hopeful, though, that debate about this bill might illuminate two major flaws in national health IT strategic planning.  The current ICD-X strategy which includes no roadmap to ICD-11 will set up the U.S. healthcare industry for strife and conflict in the 2020s when we see the rest of the world leveraging integration between ICD-11 and SNOMED to improve quality of care and control costs while we struggle to gain value from what will then be an antiquated ICD-10 coding system.  

The first flaw is the lack of a strategic plan or roadmap at a national level for ICD-X conversions.  For example, there is no mention of ICD-10 or ICD-11 planning in ONC's Federal Health IT Strategic Plan 2015-2020.    It is difficult to trust a strategic plan that fails to account for the tremendous burden that an ICD-10 and/or ICD-11 conversion brings to the healthcare industry.  The ICD-10 tactical delays can be directly attributed to conflicting strategic national healthcare priorities which resulted in an overlap of  initiatives at the local level--eRx requirements, Red Flag Rules, HITECH/HIPAA, Meaningful Use stages, PQRS, ambulatory EMR purchases/implementations/upgrades/updates and other healthcare regulations--and created unreasonable, concurrent burdens on physicians.   Tactical delays like this can be avoided through more effective strategic planning at the national level.  

It is particularly disconcerting that there is no national roadmap to ICD-11.  As I previously wrote, the U.S. is planning to achieve a short-term tactical goal of replacing antiquated ICD-9 codes while the rest of the world is closing in on their long-term strategic goal of implementing ICD-11.   Informatics experts are in agreement that ICD-11 is superior to ICD-10 and is much more integrated with SNOMED codes.   In the 2020s I believe we will see the rest of the world successfully leveraging the benefits of ICD-11 and its tight integration with SNOMED to improve quality of care and control costs, while the U.S. is struggling to gain value from what will by then be antiquated ICD-10 codes.  Cries for ICD-11 will crescendo, with most cries coming from those who do not see patients everyday.  Without an ICD-11 roadmap, we will be destined for the same predicament, only this time struggling with a short-term tactical goal to replace last century’s ICD-10 codes with no strategic plan in place to align that burdensome effort with other healthcare priorities.    

The second flaw is the lack of an effective process during ICD-X conversion planning to identify and address the concerns of grass root physicians who see patients every day.   Failing to address physician concerns prior to developing the ICD-10 solution to the replacement of ICD-9 was a strategic blunder. Perhaps the most significant physician concern is the tremendous burden placed on physician practices by the ICD-10 conversion.   Optimal planning on how to replace antiquated ICD-9 codes really should include discussions on how we might best reduce or avoid that burden.   At the very least, we should discuss how best to reduce that burden in the future, because physicians see ICD-11 coming around the corner.  

For example, we should discuss the possibility of converting from use of ICD-9 or ICD-10 to use of SNOMED codes in physician practices.  Physicians would not have to learn new ICD-X codes each time administrators decide a conversion is necessary.  Use of SNOMED codes mapped to ICD-X codes would be less disruptive to physician work flow and be more cost effective for physician practices as compared to complying with future ICD-X conversion mandates.  

The analysis on how best to resolve the ICD-9 problem should address physician concerns and result in a strategic plan that is determined to have the highest potential to improve healthcare quality at the lowest cost.  So what are some attributes of the optimal strategic planning effort?   It would be included in ONC's federal  health IT strategic plan.  It would include a national roadmap to ICD-11.   It would include a comparative analysis of the cost/benefits of completing a conversion of ICD-10 versus a direct conversion from ICD-9 to ICD-11.    It would include an analysis of  the potential to replace ICD-9 or ICD-10 codes in physician practices with SNOMED codes.   And it would include a process to identify and address the concerns of physician practices throughout the planning stages.

Dr. Matt Murray

Cook Children's


Physicians Must Level the Slippery Slope of Quality Metrics

I am concerned about the slippery slope of quality metrics that ACOs, private payors and CMS are stepping further down into.  My primary concern is that decisions being made by payors on the use of quality metrics are too often resulting in unfair or unethical use of quality metrics.   It is critical for community physicians to engage with these entities now to level the slope and establish a more optimal precedent for the future use of quality metrics.

Several years ago I participated in the Texas Medical Association's (TMA) launch of their Health Care Quality Council.  One of Council’s primary interests has been the issues inherent to pay-for-performance programs and the use of quality metrics by payors.   Some of these issues overlap onto the TMA's ad hoc Health IT Committee that I serve on as well.    Physicians in Texas have reported to these committees about unfair and unethical applications of quality metrics such as failure to consider risk adjustments for severity-of-illness or for important socioeconomic factors.   Many physicians are concerned  that they are getting overwhelmed by requests for different sets of quality metrics from different private payors as well as from CMS.   They are also frustrated by the variable, non-standardized methods by which each payor requires the physician's data to be formatted and/or submitted.

Based on my experience with these TMA committees, I have no confidence in the ability of insurance companies or ACOs to develop and use quality metrics in a fair and ethical manner without intimate involvement of working physicians from the community served by the ACOs/payors.    

There are guiding principles available regarding the fair and ethical use of quality metrics from the TMA and the AMA.     Physicians should actively engage with their ACOs and payors to ensure that these guiding principles are adhered to as quality metrics are developed.

 

 fort worthcook children's, athenahealth, meditech


Mandating Physicians to Use SNOMED codes Has Higher Potential to Improve Healthcare Than ICD-10 Mandate

I have consistently advocated for skipping ICD-10 and initiating an unprecedented effort to accelerate the development of ICD-11-CM.  Although I still believe this strategy to be the one best aligned with quality care, I fear that the sunken ICD-10 costs are now so large that skipping ICD-10 is unpalatable for most organizations, even for some physicians, and is politically perilous.  Since we must do something, I have been thinking more about the proposal to replace ICD-9 with SNOMED in physician practices.  Leveraging SNOMED to improve care, lower costs and remove physician practices from the ICD conversion melees should be a serious national conversation at this point.  
 
After several delays CMS has established October 1, 2015 as the new implementation date for the replacement of ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures with ICD-10 codes   But another postponement remains a possibility--especially when one considers the unclear reasons for action taken by Congress earlier this year to call off the 2014 implementation.  ICD conversion delays are costly to the healthcare industry and action should be taken to address the impediments that increase the risk of such delays.   One of the major impediments to address is the adverse impact ICD conversions have on individual physician practices.    
 
So let's jump out of the box of conventional charged impulses propagating across our cerebrums (thinking) to consider how to make ICD-10 optional for physician practices while still achieving our goal of dispensing with obsolete ICD-9 code sets.  One alternative is to mandate physicians replace ICD-9 codes sets with SNOMED code sets and require EHRs to incorporate translator technology that converts SNOMED to ICD codes in the background.  Since it would not be practicable to expect EHR vendors to incorporate the translator technology into their products by October 1, 2015, there would need to be an interim period where physician practices are exempt from the requirement to use ICD-10 codes sets until their EHR incorporates the translator technology.    This alternative mandate allows the ICD-10 conversion to proceed for the rest of the healthcare industry including any physician practices who see value in completing their conversion.  This mandate would reduce the current and future adverse impacts that ICD conversions have on physician practices, has higher potential to improve care, is more cost effective, helps EHRs be more user-friendly to physicians and mitigates the risk of further delays to ICD-10 as well as future ICD-X conversions.
 
I would anticipate a two-year transitional period where the ICD-10 conversion would be optional for physician practices based on an assumption that EHR vendors will need until 2017 to upgrade their products.  
 
Some opposition among physicians is likely to be encountered due to their lack of familiarity with SNOMED as well as questions about how this alternative strategy adds value to patient care.   I base that on the responses I heard from some respected colleagues at this weekend's Texas Medical Association meeting.  The unfamiliarity issue can be addressed by pointing out that many of us are already using SNOMED, but that we just do not know it.  CMS mandates that the problem lists in EHRs use SNOMED codes, so when one selects "Exercise-induced asthma" from a pick list of problems in their certified EHR, they are actually using SNOMED. 
 
More difficult to articulate to physicians is how this proposal to convert from using ICD-9 to SNOMED codes in our EHRs would improve healthcare, how it would improve their work flow and how this is more cost effective for physicians as compared to complying with the current mandate.  So I have developed the following bullet list to use when describing this to my colleagues:
 
  • Informatics experts are in agreement that ICD-9 is obsolete, and that although ICD-10 has potential to improve healthcare, ICD-11 and SNOMED have higher potential to improve healthcare. 
  • SNOMED, which is interwoven in ICD-11's development, is inherently compatible with ICD-11 and is already required by CMS to be incorporated into certified EHRs for Problem Lists--thus, mandating use of SNOMED is not really new to physicians and will not result in an added cost to physicians
  • EHRs can be built with technology that automatically converts SNOMED codes into ICD codes--thus, mandating use of SNOMED is agnostic to the version of ICD-X being used; the cost to physicians of using the translating technology is very small as compared to the cost of finishing the conversion to ICD-10 and then converting to ICD-11 in the next 15 years.
  • After we convert to ICD-10 in 2015, discussions about implementing ICD-11 will ensue; since ICD-10 is over 20 years old and is less sophisticated than ICD-11, it will become apparent rather quickly that we need to convert to ICD-11 as soon as possible in order to improve healthcare (i.e. today's argument about ICD-9)
  • It takes the U.S. 7-10 years to refine the international version of ICD codes into the U.S. version we use--since the ICD-11 international version is expected to be completed in 2017, the earliest conversion to ICD-11 in the U.S. would be 2024 unless an unprecedented effort to accelerate development took place
  • In any case, converting to ICD-10 in 2015 will result in two ICD conversions in physician practices over the next 15 years.  The proposed alternative strategy to convert physicians one time from ICD-9 to SNOMED results in just one conversion with all future ICD conversions occurring in the background without significant impact on physician practices--thus, mandating the use of SNOMED to replace ICD-9  would be a significant cost savings to physicians.
  • SNOMED codes have been developed for the purpose of clinical input; ICD codes are developed for important administrative and financial output purposes-- thus, use of SNOMED codes for input will improve physician work flow because SNOMED is more intuitive to use for physicians to describe clinical encounters; this also preserves the use of ICD code sets for the important administrative and financial functions that our healthcare system currently depends on.
I believe that if CMS is going to maintain their mandate to move off of ICD-9, then we should move on to an available coding system that has the most potential to improve healthcare at the lowest cost:
 
  • Informatics experts agree that ICD-11 is more sophisticated and has more potential to improve healthcare than ICD-10, but the earliest that a US version of ICD-11 could be available is 2024 unless an unprecedented effort to accelerate development occurs
  • On the other hand, SNOMED is already incorporated in EHRs and being used by physicians
Thus, I believe the mandate to convert off of ICD-9 is more likely to improve healthcare, improve physician work flow and impose the lowest costs if we make the 2015 conversion to ICD-10 optional for physician practices and mandate physicians start using SNOMED (with the translator technology incorporated in EHRs) in 2017.    There will inevitably be tactical challenges involving diverse groups of healthcare stakeholders to work on, but if we remain aligned to the goal of improving quality care, I am confident we will find mutually agreeable solutions. 
 
cook children's healthcare system

Health IT-related patient safety risks should inspire Congress to create a national patient safety board

The idea’s time has come. The U.S. healthcare system needs a national, independent entity empowered by Congress to oversee health IT patient safety. Now.

In today's world a health IT-related patient safety issue that is identified by a physician practice or hospital is investigated and managed in a nontransparent manner by the individual provider and the EHR vendor.  

Although the issue may be escalated to a local accountable care organization (ACO) or patient safety organization (PSO) that providers are increasingly becoming associated with, neither the issue nor the results of the investigation are reported to a statewide or national oversight entity. The patient safety data is therefore not collected, aggregated and analyzed at a state or national level. Without such oversight we are missing out on the opportunity to identify known avoidable health IT risks to patient safety and failing to disseminate knowledge on how to manage those risks. For example, if an issue is resolved at the physician practice between the physicians and EHR vendor but is not addressed at other practices that use the same EHR, then patients at those other practices remain at risk. 

I have observed EHR vendors tune in to patient safety issues more keenly in the past decade and sometimes make more visible efforts to ensure identified issues are addressed with all customers and not just the ones who report issues. And let's be clear that a majority of EHR-related patient safety risks are related to how an EHR product is being used or implemented by their clients and not due to inherent technical flaws with the vendor's product. Nevertheless, patient safety should be viewed as a shared responsibility between the physicians, their practices or organizations and the health IT vendors. Identifying and managing patient safety risks is done most effectively when all cooperate in a team effort.

In Texas there had been discussions within the Texas Medical Association about establishing a central, statewide EHR patient safety entity to monitor and manage health IT-related patient safety issues. The data would be rolled up from hospitals, physician practices and patient safety organizations across the state for aggregation and analysis. However, it became evident during those discussions that it would be feasible and much more beneficial to establish governance at a national level.

So why does this need to be a new, independent national agency charged by Congress to oversee health IT patient safety? 

Today there are many government agencies and private entities that I believe could and should contribute to patient safety surveillance and improvements, but none have the expertise, assets and time that are necessary to coordinate a national effort. In addition to the complexity involved with collecting and analyzing data from hundreds of institutions and PSOs, there are hundreds of unrelated EHR vendor products being used. There is not yet any available registry of health IT products, many of which are subdivided into multiple versions that sometimes vary widely in their available functionality. As a result, I strongly agree with the observations and recommendations described in an article by Singh, Classen and Sittig (J Patient Saf, Dec 2011; 7(4): 169-174) calling for a national patient safety board that is an independent government agency structured similarly to the National Transportation Safety Board. This entity would be charged by Congress to oversee HIT patient safety and coordinate with other agencies who can contribute to improvement in patient safety such as the Office of the National Coordinator, the Federal Drug Administration, the National Institute of Standards and Technology, the Agency for Healthcare Research and Quality, the Center for Medicare and Medicaid Services, the National Quality Forum, local patient safety organizations, local healthcare organizations who collect patient safety data, other local EHR patient safety reporting entities and industrial (EHR and HIT) trade associations. All of these entities need to function in a cooperative fashion in order to effectively identify and manage health IT-related patient safety risks.

The recent health IT report from the Food and Drug Administration Safety Innovation Act (FDASIA Health IT Report) proposes a framework to improve health IT-related safety risks including a proposed National Patient Safety Center. 

I am concerned, however, that the proposal does not appear to provide this entity with enough authority to get the job done effectively. A national patient safety entity must have the authority to not only monitor activity and provide learning opportunities for vendors and providers, but also to regulate activities, investigate events, ensure issue resolution and require compliance. I do not see enough "teeth" given to the entity proposed by the FDASIA report. 

The primary focus of a national Health IT Patient Safety Center should be on the dedicated surveillance of HIT-related safety risks and to promote learning from identified issues, potential adverse events (“close calls”) and adverse events. But it must also have the authority to effectively manage identified risks and ensure compliance with best practices for health IT patient safety.


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.

.

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


AMA's Opposition to Bill on SGR Fix and ICD-10 Delay Is a Winning Ploy

Incidental to the AMA's opposition to the SGR fix bill is that they fail to actively support the one-year delay of ICD-10 that is included in that bill.     Interesting ploy--oppose a bill that you could live with.     If their opposition fails to change minds and the bill is passed, they are not blamed by others for the ICD-10 delay and they are not blamed by us physicians for not trying to fix SGR.     They get a delay in ICD-10 and they begin hard work to fix SGR next time.     On the other hand, there is obviously no luxury of a "next time" for an ICD-10 delay once the implementation starts.

And, by the way, the dream of skipping ICD-10 and moving to ICD-11  sooner momentarily flickered in my head last night.     The cost analysis of the two possible pathways to ICD-11 would still be interesting.     However, I recognize that the sunken costs into the current pathway to ICD-11 (through an ICD-10 implementation) have grown exponentially since I wrote that blog.

ICD-11 could be implemented within 7 years if we are determined to do so.     But once we implement ICD-10 I fear the industry will not be able to stomach an ICD-11 implementation within a decade.     And if the ICD-10 implementation is a debacle, then I believe thinking about ICD-11 will cause such nausea that it will be delayed 15-20 years.   For ICD-11's sake, I hope the one-year delay holds up in order to mitigate the chances of an ICD-10 debacle this year.

                                                                                                      .