A large group in the middle has no time for theorizing, since they're already submerged in making the transition. A few CIOs are beginning to plead for an extension of the deadline (see related story, page 32). No one knows how things will ultimately shake out, just as no one can lay claim to being fully prepared. But even the most devoted proponent of ICD-10 acknowledges that the path to attaining it is laden with pitfalls-if not landmines. Following is a summation of 10 key hurdles ICD-10 represents and a primer of five lessons gleaned from organizations trying to make the transition as smooth as possible.
Fear Factor #1: Industry Preparation
ICD-10 replaces ICD-9 and will thus serve as the backbone of clinical documentation and billing. With that in mind, Jim Daley has one overarching concern about the transition to the new coding system-industry readiness. He serves as the co-chair of the ICD-10 workgroup at WEDI, a member organization that promotes electronic data exchange and standards. "Organizations are aware of ICD-10, but the problem is allocating resources to it," says Daley, whose day job is director of IS risk and compliance at BlueCross BlueShield of South Carolina, Columbia.
To assess industry adoption, WEDI has conducted five national surveys since late 2009. Its surveys constitute one of the few objective, annually benchmarked measurements available-and Daley acknowledges that WEDI members are likely to be more information systems-focused than others. "Progress is being made, but not as fast as we had hoped," he says.
According to the WEDI data, some two-thirds of payer and provider respondents have not even completed a full impact assessment-the first, critical step toward ICD-10 remediation, given the ubiquitous nature of ICD-9. The impact assessment-which starts with an inventory of systems housing ICD-9 codes-sets the stage for all future activities, Daley points out. And the relatively low level of completion worries Daley: "It's a concerning number because until you know what you have to do, you won't know the resources it will require."
Given the tangled nature of the health care revenue cycle, the number of systems impacted by ICD-10 can be enormous. Half of the 600 payers and providers surveyed earlier this year by TEKSystems, an I.T. staffing firm, say that ICD-10 has much broader impact than they expected. Sixty percent said their project plan was still in development, compared with only 22 percent who have completed it. The rest either had not started writing their transition plan or did not know when it would be completed.
Those organizations that have completed their impact assessment often get a jolt when they review the results. On the payer side of the industry, Minnetonka, Minn.-based UnitedHealth Group has inventoried over 700 systems affected by ICD-10, including "claims platforms, processing applications and decision support tools," says Ross Lippincott, vice president, 5010 and ICD-10 programs. These systems are busy: UnitedHealth processes 300 million claims annually on behalf of 38 million members enrolled in a variety of commercial, Medicare and Medicaid plans. "The systems are utilized across the breadth of our organization," Lippincott notes. And unlike the majority of the industry, UnitedHealth has finished its impact assessment.
On the provider side, the number of affected systems can also be daunting. Oakland, Calif.-based Kaiser Permanente completed its impact assessment last year. And the sprawling integrated delivery system-which encompasses its own health plan, spans nine states, and runs about three dozen medical centers-identified some 190 systems requiring either replacement or remediation, says Rob Alger, vice president health plan I.T. strategy and the co-leader of Kaiser's national ICD-10 transition effort. "About one-third of the systems are from the health plan, and two-thirds are from the providers," he says.
Fear Factor #2: Vendor Readiness
The multitude of systems that contain ICD-9 codes means that providers and payers will be beholden to software vendors to perform system remediation. Even homegrown systems will need modification to support ICD-10 codes, which require up to seven alphanumeric characters compared with as few as three in ICD-9. The number of diagnosis codes will expand from 13,000 to 68,000, with procedure codes ballooning from 3,000 to 87,000, according to the Chicago-based American Medical Association.
Therein lies the value of ICD-10. "ICD-9 falls short in many places," explains Wendy Wittington, M.D., chief medical officer at Anthelio Healthcare Solutions, a Dallas-based firm that provides outsourced labor to I.T. departments. "We have many more diagnoses and more sophisticated procedures. The more specific we can become about understanding what is going on with a patient, the better we can do comparative effectiveness research."
And while Wittington champions ICD-10 as a vastly improved clinical vocabulary, she says that physician practices with EHRs may be in for a rocky transition. "EHRs based on ICD-9 will need a switch out," she contends. "I don't have complete confidence in all the vendors that it will be smooth. There may be a couple that will get it right. But since so much in our transition to the EHR hasn't been smooth, it's hard to have faith. I say 'show me.' If we don't wake up as a provider and physician community and understand the transition has to happen, it will be painful and ugly."
Fear Factor #3: 'Shadow' Systems
A "complete" systems inventory is difficult to achieve, particularly in research hospitals where departments may have deployed systems and created databases away from the watchful eye of the I.T. department. And creating the inventory in the first place can be a daunting challenge. That's one reason the University of Pennsylvania Health System outsourced the gap analysis to a consultancy, in this case, Deloitte. "We did not have the internal bandwidth to do the gap analysis," explains Shiny George, director of HIM informatics at the three-hospital delivery system. "It's critical to take the inventory enterprisewide and also identify reports, interfaces and research databases with ICD-9," she says. "We want to make sure there are no orphans out there. We want to make sure there is an owner for each application."
