Joel Diamond 1/24/12

ICD-10:  A Brief History

Those who follow my not so regular posts will know that I make an incredible effort to avoid offensive and controversial material. Today, I will keep to the high road and offer an academic discussion of ICD-10. 

But first… a few words about the term douchebag. Not only is it regularly used on TV nowadays, it is a word frequently bandied about in hospitals—often as the quintessential description of certain patients, but more often aptly used to describe particular physicians.

The term d*bag was defined in the Oxford English Dictionary in 1968 as popular epithet for "an unattractive coed." It was later defined as "a general term of disparagement, esp. for an unattractive or boring person." Clearly there exists a need to stratify this description, not only for general insults, but also for standardized documentation and even commerce and billing. 

Many believe that ICD-10, or the 10th revision of the International Classification of D*bags, will resolve this issue. Its deep dictionary of 68,000 terms (compared to 13,000 in the 9th revision i.e. ICD-9) will go well beyond the general term for disparagement, while its 3-7 alphanumeric character codes will allow for greater specificity and detail. For instance, I do not need to delve into the benefits of ICD-10’s detailed description of body parts compared to ICD-9’s generic terms.

I believe that these benefits alone will justify the estimated implementation cost for conversion—thought to run from $5.5 billion to $13.5 billion, with additional productivity losses of $752 million to nearly $1.4 billion.

I thought it would be interesting to gain some historical perspective on this subject. (please note: the names are correct, but the facts are altered to protect the humorless).

Early History

Francois Bossier de Lacroix (1706-1777) is often credited for the first rigorous attempt to classify d*bags in his now famous Nosolgia methodica. He formalized the many ambiguous terms used in his day, such as “Beetle-headed, flap-ear’d knave,” “canker-blossom,” “bolting hutch of beastliness,” and the ever-popular “lump of foul deformity” and organized them according a rough hierarchy.

In 1837, the first medical statistician for the General Register Office in England, William Farr, noted that “the nomenclature of various miscreants in our midst is of much importance in this department of inquiry… and should be settled without delay,” which led to the 1st International Statistical Institute and it’s now famous Classification of Douchacity.

It wasn’t until the Fifth International Conference for the Revision of International Classification of D*bags held in Paris in 1938 that the more familiar insults that are still used today began to be assembled in an organized nomenclature. For instance, under the pejorative “dumb,” one could also classify “imbecile,” “idiot,” and “moron.” Furthermore, for the first time a combination term emerged, which allowed the specification of “a stupid- idiot.” Nonetheless, historians will recall that representatives from Austria and Luxembourg walked out on the sessions, as they felt that these terms did not fully express the gestalt of the true d*bag.  

The Ninth Revision

Meeting in Geneva in 1975, the now common three-digit codes were agreed upon and the currently used International Classification of D*bags-9 (ICD-9) was formalized. Most practitioners agree that ICD-9, while useful for general insults and humor, severely limits the accurate description of people we dislike. Take for instance the term “D*bag Not Elsewhere Classified.” It has serious and negative implications in epidemiological studies and retrospective analysis. Similarly, the combination term “D*bag with or without a stupid grin that one might want to punch” is frustratingly ambiguous. Finally, so much has already been written about the plethora of “worthless” E-codes pertaining to injuries (i.e. motor vehicle accident secondary to d*bag talking on cellphone,) yet the classification misses common conditions such as “d*bag at the gym who constantly looks at himself in the mirror.”

ICD-10

Now seriously, I hope the above parody sheds some light on the absurdity of our ridiculous emphasis on billing at the expense of true descriptive medicine, clinical communication, and interoperability. 

In fact, the closest real-life ICD-9 code that describes a d*bag is 301.81 – Narcissistic Personality Disorder.   

At least ICD-10 allows the more clinically rich picture to emerge:  F602- Dissocial personality disorder, with Z437-Attention to artificial vagina, Y607-During administration of enema. 

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 1/24/12

From States Wrongs: “Re: Medicaid MU. In looking at the latest CMS figures, it looks like several state Medicaid programs had no payments as of the end of December. That’s crazy.”  Yes, that’s a bit troubling. According to the CMS website, Idaho, Hawaii, Minnesota, Nebraska, New Hampshire, Nevada, Virginia, and the District of Columbia still have not launched their Medicaid EHR incentive programs, though most expect to be ready this year.

Kareo introduces an automated telephone appointment reminder service for its Kareo Max plan customers. The PM and billing service provider also redesigned its Help Center to include a more simplified layout and new search capabilities.

The eight-provider Raleigh Eye Center (NC) selects NextGen’s PM/EHR system from TSI Healthcare.

The 91-provider Commonwealth Orthopaedics (VA) contracts for SRS EHR.

By the end of 2011, over 10,000 New York State healthcare providers had enrolled in either the NYC Health Department’s NYC REACH program or the NY eHealth Collaborative. Both RECs achieved their enrollment goals.

RCM and EHR provider Office Ally reports adding 1,400 new practices in 2011. Last year  the company moved its headquarters from Vancouver, WA to San Antonio to accommodate its growing operations.

Clinical documentation vendor MD-IT names Bard Betz as CEO, replacing former President and CEO Tom Carson. Kevin Shaughnessy is promoted to president.

GE Healthcare reports a revenue increase of 1% to $5.16 billion, but operating income dropped by 5% to $953 million.

Care360 enhances its Care360 HD EHR app for the iPad, adding new features for medication management and documenting patient encounters.

E-mail Inga.

Practice Wise 1/20/12

New Year’s Resolutions I Hope to Fulfill

I gave up making personal resolutions years ago, when I realized I never stuck to them past January 10. But I do try to set a few resolutions or personal business goals at the start of every year. These aren’t business plan type financial goals. Instead, they are usually relationship growth goals.

As the owner of a small consulting firm serving mostly small to medium practices (with a few bigger systems thrown in the mix,) I have the opportunity to have very personal, almost intimate relationships with our clients. We are part of their practice family. We know a lot about their personal lives, and they about ours. I’m constantly striving to improve those relationships. They are the lifeblood of my business; the reason we exist.

Resolution #1: help my clients to understand the importance of their vendor relationships and how to foster them into practice family relationships. In particular, as practices adopt EMR software, they need to incorporate their EMR vendor and their IT support vendors into their team. I want to help my clients understand the value of their technology, and more importantly, the value of their technology partners in their practice success. With standardization of the elements of certified EMR products and generally standardized hardware, the value of technology is not solely the technology itself, but the partners who make technology successful in the practice.

I had a third-party business associate comment to me the other day that in all his years in business, he’s never seen customers treat their vendors the way that some medical practices treat their IT support vendors. He didn’t mean that in a positive way. He observed interactions between practices and their technology support vendors and was shocked that the clients were making demands and laying down ultimatums. In his mind, the demands seemed unreasonable.

It got me thinking about out why perfectly intelligent and reasonable people can seem so unreasonable and difficult to please when it comes to their computer environment. Of course, there are many factors at play here. It’s no secret that the medical field is anywhere from 10-15 years behind corporate America in the adoption of business computer systems. Smaller practices are at the tail end of that curve. They are approaching all of these major business technology changes to their practice with the adoption of EMR from a bit of a disadvantage.

Many small to medium practices don’t even use corporate e-mail before they move into a complex EMR. They often don’t understand the difference between buying a computer with Windows 7 operating system and Office 2007. They have no frame of reference of how these things should work. Nobody has set expectations for them. Vendors recommend solutions, install them, tell them how they work, and expect that they will be effective users and grateful support customers at the end of an implementation. The customers think if it’s a complex technology, it should just work. They are frustrated and fearful. We’ve upended the way they practice medicine. They don’t know what to expect. We have failed them by not setting realistic expectations.

Resolution #2: set realistic and appropriate expectations. OK, I could use this one is all areas of my life, but that’s another story. In relation to my business, my goal is to help define appropriate support expectations with my clients. Not only for my firm, but with all the vendors that help my clients keep their practices running.

We know that end users become effective with ongoing support. Part of that support should be educational about the processes, not just the products. For instance, I had a provider complain that we do too many software updates to his EMR; he only wants one a year. He thinks updates are about new features and functionality only. I showed him the Microsoft Automatic Updates history on his computer. It was setup to download and install automatically at 3:00 am.

He wasn’t aware that this was happening weekly. It answered his question as to why on Wednesday mornings when he comes in, his computer is rebooted and all his applications from Tuesday are closed. He thought he had a computer problem and nobody believed him that some days his computer rebooted itself. Understanding what software upgrades entail and why they are necessary was not something he ever thought about, until he started using an EMR.

We can’t expect them to set expectations of how their products or vendors will perform if they’ve never experienced these in the past. I certainly would have appropriate expectations about a cardiothoracic surgical procedure outcome having had no experience with one.

This is not a new discussion. There was an excellent post on this site last year about having empathy and compassion for the customer, and likewise, the customer for the support team. It dealt primarily with internal hospital teams. Those of us who provide support services to private medical practices have the extra challenge that these are our paying customers. We don’t have control over their environment or unsolicited sway in their culture. If they don’t feel like their needs are being met, they’ll take their business elsewhere.

And let’s be clear: not all vendors are created equally. There are plenty of vendors who do not meet even the minimum expectations, set or not.

Someone will read this and state that it is elementary and pedantic. Nevertheless, I see hundreds of providers in small practices, and by and large, they are in the same boat. I have a handful that are really computer savvy and understand what to expect. I value my clients and the work I get to do with them. I want to make sure they are given the opportunity to play on an even playing field, knowing all the rules of the game, so that they can be successful in this part of their business.

We can all help them set appropriate expectations. Then, hold them and us — the vendor community — to those standards. We can only expect them to have reasonable expectations if we agree to them, and then meet them.

At least I won’t be fretting over another year of wasted gym membership fees after another failed resolution to start exercising and lose 15 pounds.

Julie McGovern is CEO of Practice Wise, LLC.

News 1/19/12

Greenway Medical Technologies hopes to raise $80 million in its upcoming IPO with the sales of 6.67 million shares at $11 to $13 a share. Company valuation could hit $347 million, if all shares sell for $13 each. No official word on the date for IPO, but at least one investor predicts February 2nd.

CMS releases attestation figures for EPs participating in the Medicaid EHR incentive program. Through the end of December, 14,089 EPs received $295,760,910 for their meaningful use of EMRs. That compares to $274,590,000 paid by Medicare to 15,255 EPs.

Quest Diagnostics announces a grant program to provide eligible providers an 85% discount off the retail price of its Care 360 EHR, including fees for licensing, hosting, support, training, and implementation.

I noticed on eClinicalWorks’ Facebook page that they sponsored a blood drive at the corporate headquarters on Wednesday. Very cool.

The Arizona REC adds PatientClick EHR to its Vendor Alliance Program.

Meramec Valley OB/Gyn (MO) selects Benchmark’s billing and clinical solutions.

Physicians who have an ownership interest in their practice are more likely to consider EHR implementation difficult because they bear a certain amount of financial risk related to owning, operating, and managing a medical practice.

The Kentucky REC reaches its initial program goal of 1,000 enrolled primary care providers.

Please join me in welcoming HIStalk Practice’s newest platinum sponsor, Humedica. Humedica provides SaaS-based clinical intelligence solutions that connect patient information from varied medical settings and time periods to generate a real-time longitudinal view of patient care. The Boston-based company offers MinedShared Ambulatory, which supports clinical, operational, and financial benchmarking and earned the highest overall rating of any clinically focused BI vendor in last year’s KLAS Business Intelligence report. Humedica partners with Allscripts, as well as AMGA subsidiary Anceta, and recently announced a new predictive analytic model to identify patients at high-risk for CHF hospitalization. Many thanks to Humedica for supporting HIStalk Practice, as well as HIStalk.

Want to learn more about Humedica? Check out Mr H’s interview of  President and CEO Michael Weintraub last month.

The AMA and TransforMED release three online educational tutorials to help physician practices better implement HIT and cover ePrescribing, pre-visit planning, and point-of-care documentation.

A study by UC Davis Health System researchers finds that care for dermatology patients is usually enhanced by specialty consultations via telemedicine. The research team found that live interactive consultations can improve clinical outcomes because the consults usually involve beneficial changes in medical diagnosis and disease management.

E-mail Inga.

DOCtalk by Dr. Gregg 1/17/12

I Can’t Get No…

Every once in a while I put on a pair of skin tight leather pants, rip off my shirt, puff up my lips, and strut about frenetically with arms akimbo – somewhat like a chicken – singing Mick and company’s famous line “ I…can’t…get…noo-o… …sa…tis…fac…tion.” (There’s a visual for you!)

Having peeled the leather off and slipped into some much more age-appropriate sweat pants, I’ve stopped strutting and will now explain my lament, which of course has an HIT riff running through it.

I still love my EHR, Bond Clinician. (Since it was acquired-acquired-acquired and then sunsetted, I no longer feel any obligation to call it by anything other than its original, Bond-given name.) Yes, it has features and functionality that are less than optimal, but after looking about with a fair degree of diligence this past year, I still haven’t seen another EHR out there that comes close for overall look, feel, or technical sexiness. But, sadly, my beloved Clinician will grow more and more anachronistic as it stays forever trapped in the annals of HIT throwaways. I need to find my next EHR “Brown Sugar.”

Don’t get me wrong; I have seen some very attractive and some very functional EHRs. The problem for me, though, is mainly two-fold:

1) The good-looking EHRs are rarely evolved enough or complete enough or else they come with a heavy dose of an EHR provided to bolster the practice management/billing tool or else they’re designed to promote some other principal focus (e.g., labs) or;

2) The more highly functional EHRs are almost always just plain butt-ugly (not unlike the aforementioned Mr. Jagger.)

As I’ve stated before, I’ve seen some fantastic parts and pieces that combine both the design elegance and the Apple-esque usability that I seek. Thus, another Mick-generated semi-proverbial lyric applies: “You can’t always get what you want, but…sometimes…you can get what you need.”

The spoiled, angst-filled, teenage brat inside me rebels against this, though. My inner little monster whines, “I’ve seen beauty in EHRs. I was a part of the design team for ‘Notes 2.0’ for Eclipsys’ Peak Practice, nee Bond Clinician, which was headed toward the EHR hall of fame for both its beauty and its tech savvy wizardry. Waaaah. I want a beautiful EHR that’s just as full of gorgeously implemented function as Clinician 2.0 would have been and just as easy to use as my iPad. I want all those great parts and pieces in one fully integrated EHR. Waah, waah!”

I’ve listened to far too many vendor hyperboles to even be swayed anymore by the sales pitches. No, your tools aren’t the end-all, be-all for medical practice record keeping. No, your patient portal isn’t going to drive swarms of new patients to my door. No, your billing and scheduling functions aren’t seamless. No, “functional” is not the same as “good.” No, “usability” isn’t just about “easy click-ability” or voice recognition. No, gathering useful data is not the same as having data gathered usefully.

I again hear Mick sing “…but if you try sometimes…” when a few vendors have asked me to contribute to their product’s development over this past year. Helping create the visually-stunning and truly provider-friendly system that would lead me back to the contentment I now feel with my dear Clinician is intriguing. I mean, I helped Clinician move up the food chain and I’ve learned tons since then. I understand at least a thing or two of what it takes to make digital healthcare click. Plus, I’ve developed a pretty wide-ranging overview of this industry from my little trench (and more than a few connections that could be really handy.) Maybe I can help develop an EHR to provide a similar sense of system satisfaction to that which I now feel with my dear Clinician – and, hopefully, help some fellow providers feel the same as they digitize.

Thus, I’m considering the possibilities, at least with a couple of them. I’m not yet committed because it isn’t just the consulting that’s important to me: the heaviest factor is that I’ll be also using it as my next EHR, using it every day. Being a happy with what I currently have makes the thought of changing a bit tough.

With a rather different position, perspective, and experience base than most docs (who are typically less geekoid, likely to their benefit,) it does make some sense to try to make a difference. “But, I try, and I try, and I try, and I try…,” goes the Mick within my head.

If I do go the consultancy way in some form or another, I’ll try to create a relationship that doesn’t cloud my trench grunt blogger perspective. I absolutely need to get on with getting a new EHR, but I highly value the honor of being able to write “from the trenches” here on HIStalk/HIStalk Practice and want to maintain the uncluttered honesty it allows.

Mr. Jagger has said, “It’s all right letting yourself go, as long as you can get yourself back.” My fear: some consultants never quite seem to make it back.

From the Stoned trenches…

“I’d rather be dead than singing ’Satisfaction’ when I’m 45.” – Mick Jagger

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).