HIMSS/Physician IT Symposium: Mapping ICD-10, NY HIE efforts
LAS VEGAS—“As someone co-leading ICD-10 implementation for a huge company, last week was an interesting week,” said Rob Alger, vice president, health plan business technology solutions and services, Kaiser Permanente. He was speaking of the announcement that the Department of Health and Human Services will delay the required ICD-10 implementation deadline during the Physician IT Symposium on Feb. 20 at the 2012 Healthcare Information and Management Systems Society (HIMSS) conference.

ICD-10 offers enhanced categorization models as well as greater detail, severity and risk definition, precision of definition, forward flexibility and ability to integrate clinical documentation, Alger said.

Unfortunately, ICD-10 was first adopted in 1990 which means it captures the state of healthcare in the late 1980s, he cautioned. “There’s a lag to this process that’s very hard to get past.”

ICD-10 implementation is estimated to require a $100 million investment and that doesn’t account for change management, Alger said.

Early analysis from Kaiser showed very specific areas of impact, however Alger said they found they could crosswalk from ICD-9 to ICD-10 “better than we thought.” Out of a sample of 4,200 records, 93 percent were mappable to ICD-10, he said.

The challenge right now, he said, is the uncertainty. “Every organization has a choice to make about going forward with ICD-10 implementation. A significant investment has already been made so we’re going to stay the course. There is less cost in completing this than in slowing down, stopping and then picking back up again.”

John Blair, MD, president of Taconic IPA, also spoke during the session and compared the Fishkill, N.Y.-based health information exchange (HIE) with the Direct Project. Taconic covers the whole horizon of delivery models and works with six different health plans, he said. There’s only going to be more and more information with unintended consequences of increased chances of error, he said.

Blair explained the differences between his HIE and Direct and the need for both. The 10-year-old HIE is more about unanticipated arrival of patients in an emergent situation while Direct is geared to anticipated patient encounters. The HIE is available to all providers who participate while Direct involves one-to-one provider push. Direct is “all about the EHR system and moving data from one EHR to another,” Blair explained. The community sponsors the HIE and dictates and handles privacy policies and governance of exchange while Direct is more about EHR vendors handling that aspect and bundling that capability into their systems.

Direct is for referrals and consults and is more about care transitions. Blair said there is demand for Direct because “the best patient care requires communication. Physicians need information as patients transition across care environments.”

Ultimately, he said, you want, whenever documentation moves between systems, for that system to have the ability to reconcile medication and problem lists.

The documentation includes core data and variable data. The variable data “needs to be what’s clinically relevant at that time.” For example, the relevant information sent to a cardiologist is going to be different from that sent to a dermatologist.

Another issue is that data are not adequately constrained, Blair said. “One system may not understand the structured data of another system.”

To tackle these challenges, the first order of business, Blair said, is standards. If the standards are the same across the board, all systems, regardless of vendor, can communicate effectively. Blair said he does clinical side work with vendors in which there is a process for understanding how to make software more manageable. Software is installed at one or two sites and beta tested to see how well it works for physicians. “Usually, they have to go back and optimize. It’s not just about connecting system to system but sending and receiving and getting into the workflow so it works for providers.”

Timing is everything, Blair said. Studies of Danville, Pa.-based Geisinger Health System found that the lion’s share of costs were due to hospital readmissions. “The greatest impact was having an active medication reconciliation list so providers could call complex patients and go over their medications. They found that more than 50 percent of the time, there were errors that could have resulted in readmissions.” Waiting to review those medications until three or four days after discharge is too late for high-risk patients, he said.

That’s where the difference between the discharge summary and the discharge message comes into play. The discharge message is “actionable that day when the patient is discharged. We want the primary provider responsible for the patient to do medication reconciliation and get a follow-up visit scheduled,” Blair said. So, the discharge message only includes the most pertinent information.

Once providers start to experience the benefits of the systems, they want more, he said. “Providers want us to move as fast as we can. It’s been very interesting trying to keep up with what they want.” However, Blair said they must first crawl, then walk and ultimately run.

Meanwhile, the first step is getting standard interfacing and integration in place, then structured data and later workflow improvements. “The Direct Project is far enough along that, for vendors, the next piece really is going to be software design so it’s useful.”