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Reaction to ICD-10 delay a mixed bag among health care CIOs

Some health IT leaders don't see value in CMS's promised ICD-10 delay. Even more wonder where to find the ROI in using ICD-10. The impact of the 'unfunded mandate' is being felt.

Last month the Centers for Medicare and Medicaid Services (CMS) announced it would accede to the American Medical Association's request for an ICD-10 delay. Judging from Tweets and informal conversations at the Health Information and Management Systems Society's HIMSS 2012 conference, health care CIOs' reactions ran the gamut from frustration at the amount of political capital burned in the C-suite to get ICD-10 implementation rolling to grateful relief that a deadline extension would afford more time for the technology initiative.

According to the Feb. 21 HIMSS Analytics report commissioned by coding vendor 3M Co., most hospitals have assembled ICD-10 steering committees to tackle system-wide implementation issues such as how to go about training staffers involved in the changes from ICD-9 code, assessing vendor and payer readiness for ICD-10 and calculating its financial impact.

Vendors and payers appear to be more upset about the ICD-10 delay than providers, said Carl Ferguson, managing director for CTG Health Solutions, a consulting firm that provides implementation help for payers and providers with quality reporting programs, ICD-10, meaningful use and other IT projects.

"Those people who spent the money on ICD-10, they're really unhappy about this announcement," Ferguson said. He ran into the global sales director of a large coding vendor at HIMSS who was upset about the delay. "They spent a lot of money, they gave a lot of free stuff to CMS to make sure ICD-10 was going to come out on time, and they really feel betrayed."

Several clients that Ferguson has spoken with since CMS announced the ICD-10 delay weren't planning to delay spending on it, he said, although they indicated they might not go as fast and hard toward finishing it by the previously deadline of Oct. 1, 2013. (CMS has yet to set a new deadline.)

Smaller providers seem to be happier about the ICD-10 delay than larger ones, said Frances Dare, a senior executive for Accenture Health. She suspects it's because successful ICD-10 implementation requires a lot of people resources. The smaller the provider, the fewer people to devote to ICD-10.

"The ability to manage the change-management piece, that is reflective of size of the organization," Dare said.

Revenue management upgrades coming along with EHR system

In theory, if a health system is upgrading or replacing its electronic health record (EHR) system, one way to assure the latest in ICD-10 preparation is to change the revenue cycle management application as well. Some hospitals in the midst of an EHR switch are doing this, not for ICD-10 compliance but because a particular revenue cycle management system integrates better with the new EHR system -- especially when both are from the same software vendor.

Perhaps you can define quality and care better…but is it really that much better for the amount of disruption and money it's going to cost?
Tom Hargrove, M.D.CMIO, Trinity Mother Frances

Howard Landa, M.D., CMIO of Alameda County Medical Center in Oakland, Calif. said his facility hasn't yet focused on ICD-10 in part for this reason. The rip-and-replace wasn't designed to coincide with the transition to ICD-10 codes. "It just kind of lined up nicely," he said.

"Maybe I'm stupid and naive," Landa said, "but we haven't put a whole lot into ICD-10 yet. We had lined up a whole bunch of consultants to come in and start -- right about now -- and with the [CMS ICD-10 delay] announcement, we've put them all on hold. We're putting in a system that's already ICD-9 and ICD-10 compatible, and we'll switch over to it during the transition year."

Depending on the length of the ICD-10 delay, he said, it might work out well for Alameda as they sunset the old system, and some of the parts that go with it, and bring the new ones online. It also might let Alameda more thoroughly test the new software in transactions with payers before ICD-10 goes live, whereas the bulk of that testing might have been done on the old system had CMS not announced the delay.

Trinity Mother Frances hospitals and clinics in Tyler, Texas are also ripping and replacing EHR and revenue cycle systems in a switchover to Epic Systems Inc. software, said CMIO Tom Hargrove, M.D. He said he's neither happy nor frustrated with CMS's announced ICD-10 delay but, rather, somewhere in the middle.

Like Landa's, the ICD-10 component of Hargrove's switchover was serendipitous, but he'll take the favorable timing. The new Epic software will have computer-assisted coding components that will help guide physicians in creating documentation for the more specific ICD-10 codes, and will assist coders in steering toward accurate codes. While the software doesn't pick codes, per se, it can ask practitioners questions about a diagnosis that, in the end, will fill in holes the coders will need to submit claims.

"Our organization spent a lot of its ICD-10 money buying our EHR software," said Hargrove, adding that Trinity Mother Frances will keep continue on its ICD-10 implementation plan as previously scheduled unless it hears something dramatic from CMS. After all, the organization has already spent the money on its new system.

"It's going to be ICD-10 workable -- meaning there will be work to get to it, still -- and of course we'll have deal with all the bolt-ons, other vendors, and other people we have to work with every day, and continue to train our physicians and clinical staff," he said, "but [upgrading the EHR system] eases that transition somewhat."

CIOs question ROI of ICD-10 implementation

No matter which opinion CIOs held regarding the delay in ICD-10 implementation, it seemed that most had the same question the Medical Group Management Association posed in its letter to the Department of Health and Human Services: What's the return on investment for ICD-10?

While the World Health Organization is convinced of the clinical value of ICD-10 and ICD-11, due for completion mid-decade, not all U.S. health care CIOs see it.

Count Kathryn Stout, M.D., CIO and managing partner of the Virginia Women's Center, which operates five specialty facilities, among the ICD-10 transition skeptics.

"The new system requires a tremendous amount of energy, expense and engineering, for -- arguably from our standpoint -- zero improvement on patient care," Stout said. "I have yet to find anybody in our specialty who says we're going to do better care with ICD-10…it just doesn't exist. Our focus has always been improving patient care. The problem is, it doesn't meet that goal."

Hargrove said in discussions with his peers, the same question's coming up: What are we really getting out of ICD-10? "There's a lot of money being spent by payers, by software companies, by providers trying to get ready for this," he said. "We're going to have better, granular codes. Perhaps you can define quality and care better…but is it really that much better for the amount of disruption and money it's going to cost? I'd like for CMS to really think hard about that…and just give us a date."

Ferguson said that providers' coding teams are probably the most worried, with some he's talked to estimating that coder productivity will decrease 50% as they spend more time pinpointing which ICD-10 code properly describes each diagnosis. He also has heard fears that up to half the coders will quit, not wanting to learn ICD-10. The delay, he thinks, will come as welcome relief to providers, who now have time to conduct more robust pilot projects to confirm these fears -- or disprove them -- and better prepare for ICD-10 changes when they actually goes live.

Some fear ICD-10 delay will lead to disaster; others aren't worried

After assessing the potential problems ICD-10 could bring -- from ill-prepared payers stalling out hospital revenue flow to EHR and billing systems crashing -- some CIOs are nervous about the health care system's ability to implement the new coding language.

Stout is "absolutely thrilled" for the extra time to prepare for ICD-10 codes, and she's not sold on the ROI of the new disease classification language. So far, her organization's ICD-10 preparation is in the information-gathering stage. From those efforts, Stout characterized the steering committee as "scared to death" of the havoc the "unfunded mandate" of ICD-10 will wreak on Virginia Women's Center's ability to provide quality care.

"Particularly with the limited resources of an ambulatory practice facility -- which is what we are -- we have to be careful we don't waste too many resources preparing for every incremental initiative that comes out," Stout said. That being said, "with the complexities and number of codes, [ICD-10] is entirely overwhelming."

While logic might seem to dictate that specialists might have an easier time adapting to ICD-10 because the use only a limited subset of the code set, Stout said it's going to be a thorny transition for staffers to get up to speed. For example, a diagnosis that has one code now -- ovarian cyst -- will be subdivided into about 20 different codes in ICD-10, which adds details about size and location of the cyst. Training staffers to provide enough detail so coders can derive the right ICD-10 code -- after ICD-9 had required only general details -- won't be a simple task for her team.

Others, however, don't fear the transition, for all its complexities. Alameda's Landa said he was asked "How are you going to teach physicians ICD-10?" After thinking about it, he responded, "How did they learn how to use ICD-9?" The answer: Without formal training.

"It's not something we were ever taught, we just started doing it," Landa said. "There's a lot of whining, a lot of quibbling, but the bottom line is: If you've got a reasonable search tool, [you]'ll figure out how to find something."

Let us know what you think about the story; email Don Fluckinger, Features Writer or contact @DonFluckinger on Twitter.

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