Does ICD-10 pilot forecast a perfect storm for healthcare?

Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.

But I ask you, oh gentle, patient reader, how could I not?

Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.

And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.

Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.

Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”

Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.

The end-to-end testing approach …

…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.

And how did this pilot testing go? (Cue dark, foreboding music here …)

The average accuracy was in the 60 percent range with low scores around 30 percent.  Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great. To be more specific:

  • 40%: Chest pain, unspecified
  • 33%: Closed fracture of unspecified part of femur
  • 45%: Coronary atherosclerosis of native coronary artery
  • 40%: Congestive heart failure, unspecified
  • 42%: Degeneration of the limb or lumbosacral intervertebral discs
  • 46%: Acute chronic systolic heart failure
  • 29%: Sebaceous cyst
  • 35%: Closed fracture of the intracapsular section of femur, unspecified

Predictably, the pilot identified coding-based challenges as the primary cause of low accuracy rates. Some are easily solved. Others, not so easily. You be the judge of this coding error best-of list:

  • Mixing up similar letters and numbers
  • Technical glitches with uploading and transmission of documents
  • Overworked coders
  • Incomplete EHR documentation
  • Coders forgetting key aspects of ICD-10 not present in the ICD-9 code set

Of course, all these errors require understanding the problem and tackling it within the context of process and team. If test subjects scored lower than 50 percent accuracy coding common diagnoses even after a well developed and implemented training program, what will mainstream providers achieve?  How much worse might they be?

I am speaking primarily of resource constrained provider organizations that are already on the edge financially, not Partners Healthcare or Mayo Clinic. For them, I think these pilot study figures portend a financial disaster: 50 percent coding accuracy means 50 percent claims denial and a precipitous decline in revenue. How will they make the needed changes to increase accuracy when organizations in the study could not?

According to the frank assessment offered by pilot study organizers, they will just need to focus.

The “perfect storm” will be quickly descending upon the healthcare system ... All ICD-10 impacted organizations should act now to allocate as much time as possible for testing and remediation to protect their corporate bottom lines and cash flow to successfully achieve compliance.

While the pilot does not actually quantify the time and resources required for organizational change and ICD-10 compliance, a comment on the pilot offered by one physician speaks of an exhausted profession that can’t see a better day on the horizon.

As a practicing physician and using EHR (sic) for last 10 years, the last 2 with Epic both in office and hospital, I cannot image (sic) what this will mean. I now spend 11 to 15 hours a day, Monday through Friday, plus many hours on the weekend working on the computer. This ICD-10 sounds ridiculous to try to implement on top of everything else.

While I’m in partial agreement with Dr. John Halamka of Beth-Israel Deaconess and Harvard on this one, I don’t think his suggestion of a 6-month ICD-10 extension is enough. What will be so significantly different in 6 months? In that timeframe, I think the challenges that exist now—Meaningful Use Stage 2, the upheaval of the Affordable Care Act--will pretty much be the same. While I don’t expect it to happen, I’d suggest we delay ICD-10 until innovation makes it less of a burden. I can’t say when that will be, but I do have faith that it will happen.

It’s not that ICD-10 is an inherently bad idea, or that hospitals and providers can’t meet the challenge with reasonable deadlines. But they have too many challenges right now, and we are forgetting that most of healthcare is small provider organizations, regional and county hospitals and critical access facilities. If Kaiser struggles with MU, the ACA and ICD-10 all at once, what is a county hospital in Kansas or Idaho, or New York or California, supposed to do? When their reimbursement rates fall, they will face bankruptcy, and vital healthcare services will disappear from the areas that can least afford to lose them.

Yes, it is a clichéd pop-culture reference, but we truly are looking at a healthcare perfect storm like no other next year. We expect that this confluence of challenges will eliminate some health IT companies, and we generally accept that the herd needs to be thinned anyway. But can we be so sanguine about the potential impact on healthcare itself when financial ruin and simple emotional overload seem highly possible, even likely?

Providers will be driven to the brink, and I cannot see how this ends well for American healthcare, which I thought was the original goal.


Good post Edmund, but I think you may be more optimistic than I.

I was having lunch with my 93 year-old father and his 97 year-old lady friend, and asked them how they liked the new EHR system their medical clinic had installed (Epic).

He said, “Well, I suppose it’s more efficient, but my doctor seems to spend all his time typing on the computer… and getting mad at it.” She said, “I don’t really get a chance to talk to my doctor much anymore. Everything is so rushed, and he is so distracted by his computer, that I have to write down my question in advances to try to get his attention.”

I see us heading to a complexity catastrophe. Everything coming out of HHS piles on layers of complexity.

The exploding number of ICD codes has some perverse information theoretic implications. The vast set of mostly-unused codes (and some impossible) increases the uncertainty (and coding error potential) of the more likely ones.

So, if we are having trouble coding common codes like CHF, having “W59.83 Crushed by other nonvenomous reptiles” creates a rabbit hole worthy of the White Rabbit in Jefferson Airplane’s song.
So, introducing

I agree with your view on complexities but I would ask your 93 year-old father and his 97 year-old lady friend what they discussed with their doctor “pre” EMR? At their ages, the paper file alone would be longer than the ObamaCare bill! As the world turns, I can envision a day when the value gained from an EMR far exceeds the pain of utilizing one. I believe this day is far off in the future but it is inevitable and will only get better. I can read my “chart” via my iPhone while sitting in the waiting room for my GP. I know my labs, rads, paths, etc. way before my GP does. I bet dad would think that’s “cool?” Cheers to modernization.

Great eye on the storm Edmund. I said a long time ago ICD-10 conversion would make Y2K look like a joke. Oh wait, Y2K was a joke. ICD-10 itself will be a good thing for US health care in general, but with all the other things on the IT roadmap the costs to organizations is nothing short of completely ridiculous and the deadlines almost unattainable. We’ve lost sight of the patient in a morass of administrative burdens and dirty data.

Hey, but what about all the benefits from ICD-10 that we’ll miss out on if we delay it. Oh wait…those must have gotten lost in the storm.

Being very specific on diagnoses and procedures can be very valuable. But, not if it interferes with actual care and decision making. What is needed is innovation where clinicians just express the care and have the ICD 10 derived from that expression.

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