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  EDITOR’S NOTE: With the publication of the Heritage Foundation’s position on ICD-10, ICD10monitor asked two physicians to weigh in on the matter. Andres Jimenez, MD, is the co-founder of ImplementHIT. His reaction appears first, followed by that of Joseph C. Nichols, MD, principal of Health Data Consulting.

I want to preface my own statements about ICD-10 by recognizing that I have several biases, as do the Heritage foundation, American Medical Association (AMA), and others, and this certainly influences my thoughts regarding ICD-10. I am a physician, and I recognize the challenges inherent in the work, such as long work hours (averaging 53 hours per week) and an overabundance of federal initiatives such as value-based purchasing, the readmission penalty, hospital-acquired conditions, and others that are already impacting the way we practice as well as our compensation. I feel the pain of fellow physicians still struggling to adopt an electronic health record (EHR), and many associated wounds are still unhealed at many organizations around the nation; a 2014 Physician Foundation survey indicated that 46 percent of respondents felt that the EHR has detracted from their efficiency.

Being a physician is not my only bias, however; as founder and CEO of ImplementHIT, I am also a training platform vendor partnered with the American Health Information Management Association (AHIMA), which exclusively uses our training platform for their physician ICD-10 training program. Therefore, I profit if ICD-10 continues forward.

There is, however, one bias that continually gets overlooked during these discussions, and that is the bias of the patient. It’s on my mind every moment, with my wife currently being 38 weeks pregnant with baby No. 3 and having gone through about 34 weeks of regular physician encounters to date. I’ve also been reminded of the patient perspective this past year with a family member who was diagnosed and treated for a rare gall bladder cancer, and an 82-year-old grandmother who was discharged and readmitted from a hospital in New York four times within five months. In the Heritage Foundation report, they started to touch upon the importance of codes to make it easier for “researchers and healthcare analysts to retrieve data to support measuring and improving health care services; supporting disease management programs; and enhancing the ability to conduct public health surveillance.” They referenced the use of SNOMED CT, which is in fact even more detailed than ICD-10, with over 300,000 defined concepts. For instance, the stage of a malignancy is included in a SNOMED concept, whereas in ICD-10 cancer stage currently is not, and I emphasize currently because the upgrade to ICD-10 is as much a framework shift to support future expansion as it is the total number of codes that exists today. But should we really keep ICD-9 and add SNOMED? In the wrist fracture example referenced in this report, the ICD-9 code doesn’t even allow you to capture laterality, which certainly has plenty to do with the patient’s clinical situation. 

That said, it turns out that about 350,000 physicians across 2,500 organizations in the U.S. are not directly selecting ICD-9, ICD-10, or even individual SNOMED CT codes when they select a problem for the patient’s problem list in the EHR; they are selecting a “clinically friendly term” from IMO (intelligent medical objects) that is integrated into their EHR, and it simultaneously maps to all three: ICD-9, ICD-10, and SNOMED. But the key part to this all, and how it impacts patients, is that unless a single code nomenclature links compensation with the quality of care delivered to patients, very little change will take place in a system that could be providing them with better care. And when you use a single code nomenclature as a basis to link quality and compensation via comparisons, which will be the case for 90 percent of Medicare fee-for-service payments by 2018, those diagnosis codes must be granular enough to account for details known to impact outcomes – making it a fairer system for both patients and their physicians, and better supported, with 69,000 ICD-10 CM codes compared to 14,000 ICD-9 CM codes.

The Importance of Capturing Data

The recent article published in the Heritage Foundation (The New Disease Classification: Doctors and Patients Will Pay) focuses on the negative impacts of ICD-10 on healthcare. Typical of similar articles, it assumes that healthcare with little visibility into the services delivered and conditions treated is acceptable. Currently we spend far more than any other nation per capita for healthcare, and there is little reliable evidence to support the benefit from this spending. Our current population data is so unreliable that the most we can measure is what encounters and procedures occurred and whether a person was born or died. Based on the only reliable data we have, we do know that our longevity is substantially less and our infant mortality substantially higher than many other nations that spend far less.

In order to improve healthcare in this country we need to know not only what was done, but why. The understanding of services is only relevant to the degree to which we understand the health condition that the service was meant to improve (or at least maintain). Without accurate descriptions of the patient’s health state, we have no idea whether healthcare is of high value or even safe. Payments should be based on value. Value can only be determined in light of the quality of care as measured in the maintenance or improvement of the patient’s health state as compared to the cost of delivering that care. ICD-10 is the only viable national coding system, and to some degree, international standard, that we have to define the health state of the patient. Without reliable information about the health state of each patient, we are operatizing in a health policy vacuum. Without this type of information we don’t know if the services we provide help or harm.

“Trust me, I’m a doctor” isn’t working.

Every other industry requires data to ensure that services and products are of high value and delivered safely. Data is a requirement. There are stringent requirements for reporting accurate data about a variety of parameters in the field of aviation, for example, and this data is captured accurately and provides the information needed to support a safe, high-quality service for travelers. Key data in the food industry ensures that our orders in restaurants are accurately and safely delivered. In none of these industries is the capture or reporting of this data unfunded or considered an unusual burden. It’s a cost of doing business in an environment where data is important to the industry and its customers.

Capturing, reporting, and analyzing data regarding the key parameters of the patient condition is critical to ensure the value and safety of healthcare delivery in this country.  

About the Authors

Dr. Jimenez is the founder & CEO of ImplementHIT, a physician and PhD Candidate in adult education, and his company’s training software is used by hundreds of hospitals to train physicians on ICD-10 and their EHR.

Dr. Nichols is a board certified orthopedic surgeon and is an AHIMA-approved ICD-10-CM/PCS trainer.  He has a wide range of experiences in healthcare information technology. Presently he serves as the president of Health Data Consulting Inc.

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