For successful conversion to health care's new medical coding system, hospitals must implement waves of enabling information technology, make exacting changes to existing IT systems, and adequately educate all those whose working knowledge of about 14,000 coding choices will have to expand to nearly 70,000. Health care executives might figure they have all they can handle readying the means to convert their organization's myriad medical activities into the alphanumeric language of ICD-10 codes.

But it's all too easy to forget that those medical activities first must be documented by the doer — in most cases a physician — before there's anything for the IT system to make available to the coder and for the coder to turn into something that meets requirements for medical claims, analysis and research. "Our coding is only as good as the documentation," says Kathryn DeVault, director of professional practice for the American Health Information Management Association.

That maxim will be pivotal in the remaining months before the transition to ICD-10 takes effect in October 2014. In the final analysis, "it is about the physicians providing the raw materials," says Stephen Stewart, chief information officer of Henry County Health Center, Mount Pleasant, Iowa.

Busy doctors don't have to learn all the codes themselves. But they'll have to be prepared, prompted and pursued, if necessary, to tell a more detailed story of their day-to-day work so those responsible for the final coding result are able to accomplish it with the information provided.

When it comes to physician documentation, "that's the core of this transition, and that is the heavy lifting," says Mary Anne Leach, vice president and CIO of Children's Hospital Colorado, Aurora. "Some organizations may have a lot of IT upgrades to do, but that's an upgrade — IT is pretty good at that, we do upgrades all the time. … The IT work is significant, don't get me wrong, but I think the bigger change management piece is the physician documentation."

The first step in managing that change for many organizations will be to impress upon the medical staff that they are intimately, rather than peripherally, involved in the ICD-10 coding process. After returning from an IT forum in 2010 that made him fully aware of the magnitude of ICD-10, Stewart had trouble conveying it to the independent practitioner whom Henry County, a critical-access hospital, pays to be its IT medical director. "He said, 'Our coders will take care of it,' and I said, 'They can't.'"

It's up to hospital leadership to supply the technological and human infrastructure for physicians to create more, and more specific, documentation than they've been responsible for producing in the past. "We need to make it easy for them, and we need to increase their awareness," says Melinda Tully, senior vice president of clinical services and education at J.A. Thomas & Associates, Atlanta. That likely includes positioning intermediaries between doctor and coder who know both clinical practice and information management. It also may call for advanced IT to collect data quickly, easily and accurately.

Attention to detail

An opening message to physicians is that they need not be spooked or overwhelmed by the proliferation of codes. The main objective is not to make more work for them, but rather to enable coders to capture more fully the story being told about a patient in the notes and observations that practitioners dictate or enter into medical charts. Done right, the information should be there anyway.

"The whole purpose behind documentation is to ensure that what is performed and what is diagnosed accurately and thoroughly reflects the condition of the patient, the services rendered and the severity of illness," says Maria Muscarella, assistant vice president for health informaton management and electronic medical records at Newark (N.J.) Beth Israel Medical Center.

The key word is specificity, says Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. "It's how you tell the story. In other words, don't skip too much," she says. For most of the added specifics, "they know it in their heads, but it's a matter of getting it documented so that the coders can pick it up."

For physicians, it's also about "really changing their language" regarding how they talk about patients, says Nicholas Holmes, a pediatric urologist at Rady Children's Hospital in San Diego and medical director of its program to shore up clinical documentation. In medical school, doctors learned, in effect, a foreign language of description that may be fine in a conversation with another doctor, but falls short of letting other users of a record know what's going on, says Holmes. Physicians now have to grasp "that the language that was OK and acceptable that they learned many years ago is probably not the most accurate way to talk about patients," he says.

At a minimum, the coders need the basic details, and from there they can take over and match the information to the proper codes, says Stewart. "It's getting [physicians] to see it's not about information they don't have and they don't know. It's about how they communicate it."

That's the physicians' part of the bargain in making ICD-10 documentation succeed. On the hospital side, "We need to make it as streamlined and simple as possible so the physicians can concentrate on what they do best — being caregivers, making decisions — and not spending nights and weekends working on documentation," says Leach.

Enter the clinical cavalry. Health care organizations intent on taking the load off physicians while averting documentation misadventures are putting so-called clinical documentation specialists in the corridors and offices where doctors go about their business. Also called physician liaisons, they have either a nursing background for the clinical depth needed to understand the physician's world, or a strong coding background to know instinctively the missing information needed to properly code in ICD-10.

Children's Hospital Colorado plans to double down: clinical documentation specialists up on the floors communicating with physicians, and coders actually embedded with clinical specialty teams as they traverse the facility. "When they're rounding, and as they're documenting, we're going to have coders trained in those specialties to really help [physicians] think about what they need to be documenting," says Leach.

Part of the strategy is a sort of on-the-job training. Leach says Children's will code in both ICD-9 and ICD-10 in the run-up to the transition, "and we plan to engage physicians during that time — 'this is how we coded it in 9, this is how we coded it in 10, but this is how we could have coded it if we had this, this and this.' So, part of it is just educating them on what is happening and why it's important."

Tactics differ on the credentials of those constituting the physician support system. J.A. Thomas, which contracts with hospitals seeking clinical documentation improvement services, recommends hiring registered nurses, not coders, who are trained to get doctors to "tell the clinical story of the patient," Tully says. Then the physician can be asked to clarify aspects, and a clinical discussion can take place.

Muscarella of Newark Beth Israel, on the other hand, says accuracy and thoroughness entail "having people who are well-trained and seasoned coders with strong clinical knowledge." They review the record while the patient is still in the hospital, "what the doctor has documented so far, and then based upon their coding knowledge, query the record to have more specificity or to clarify ambiguous or conflicting or, at the time, incomplete information."

Whatever the approach, it has to be concurrent with the care being delivered and in the context of a relationship with physicians, Tully says. "If you're sitting in an office, just reviewing electronic records and pushing out electronic requests for documentation, you're never going to be as successful as if you have a face-to-face with that physician — 'Do you have any questions? Let me explain this to you.' So these clinical documentation specialists have to be very clinically credible."

It's not like problems with missing information didn't exist until now, says Harry Rhodes, director of practice leadership for the AHIMA. Getting physicians to consider the specifics and the context of the patient's problems in documentation always has been a challenge. It's become more so with the rise in chronic illness, he says: A doctor will document the current problem, but give short shrift to the secondary problems that affect the overall quality of care and reimbursement.

Smart use of support staff

The intense support, if extended indefinitely, would add significantly to the staff count but, as a practical matter, it has to be a transitional tactic in stages, moving from one medical setting or specialty to the next in priority order, Leach says. "You can't effectively do it all at once; you need to focus your resources. Nobody has 20 FTEs to throw at clinical documentation. We have to be really smart about this."

That means analyzing the impact on each clinical specialty, including the time and intensity involved in bringing the physicians to a level where they can go it alone. "As we complete the analysis of which specialties [to key on], it might just be five specialties for three months; then we might do two specialties for two months," she says. "I don't think we're going to have to do 30 specialties in a year."

Prioritized just by number of new codes, dermatology will see a 366 percent increase. Cardiology codes go up 235 percent and endocrinology 162 percent, according to statistics provided by J.A. Thomas. In contrast, while infectious disease is a high-volume admission in most hospitals, the code change is only 2 percent. "So are you going to bank all of your education on your I.D. guys when there's not going to be that many changes in the codes to describe what's going on with the patient?" Tully asks.

The proliferation of codes is harder to quantify for orthopedics, which gets into not only musculoskeletal anatomy, but all the associated signs, symptoms, injuries and trauma. But a lot of it is just being able to specify the part of a body entering into diagnosis and treatment, DeVault says. A prime example: For finger fractures, the proliferation of codes from 8 to 64 is nothing more than a reflection of the two hands, 10 fingers and multiple parts of each finger. A physician just has to supply one fact: exactly where it occurred. "A good orthopedic doctor is going to document that now."

Priorities for physician support may be determined in other ways. At Sharp HealthCare in San Diego, a big initial focus will be on hospitalists and others, such as critical care intensivists, practicing full time in its four hospitals. "They're with the patient constantly, they're doing a progress note every day, they have a lot of the documentation requirements," says Bill Spooner, senior vice president and CIO. Moreover, hospitalists "become the best educators; they have the rapport doctor-to-doctor."

Making information granular

The overall demand to draw data out of physicians' heads and into computerized form — for value-based purchasing and quality-of-care measurement as well as ICD-10 — elevates the need to capture much higher volumes of data on a daily basis, and as structured, retrievable elements rather than in a string of free text.

Electronic health records must capture data discretely as a requirement of the federal HITECH criteria governing meaningful use of the technology. The ways they capture information, such as templates of key phrases and check boxes, may be right for some clinicians but unappealing to others.

That has kept many physicians wedded to dictation. And although the technology has matured for speech recognition in the jargon-laden health care field, it still amounts to free text in electronic form unless there's some way to lift elements from it and make each important bit of data usable for reporting and analysis. In other words, granular.

Since mid-2010, Sharp has been reviewing emerging IT products that capture dictation electronically and then convert it into discrete elements that can be turned into diagnosis and procedure codes. The conclusions: Technology is capable of "presenting a reliable, accurate rendition of speech dictation," Spooner says. "In terms of turning that into codes … I think that's still to be proven."

Children's Hospital Colorado also is monitoring options for computer-assisted documentation "so we can prompt the physician to document everything we need," Leach says. "I don't think those products are ready for prime time … But, I would say that in two or three years, they will be."

Meanwhile, hospitals can make progress on collecting information for ICD-10 and other documentation by automating its intake and investigating IT products that assist in the coding. Children's already uses a speech recognition product and, in combination with EHR templates, has reduced transcription costs by $200,000 to $300,000 a year. The few transcriptionists that remain, now that voice capture is predominant, become editors rather than typing it all out, Leach says.

Sharp's 400-physician Rees-Stealy Medical Group has used a voice recognition product for about four years, and transcription costs have dropped 70 percent during that period, Spooner says. The group's leadership recently directed that physicians will no longer be allowed to dictate the old-fashioned way. "If they have any outside dictation, they're going to pay the transcription costs themselves," he says.

In the face of the higher level of reporting required of physicians, Sharp plans to use a combination of EHR templates, speech recognition and natural-language processing to get data down to a granular level while facilitating frequent and voluminous documentation for physicians. "What we're trying to [do so we] share in the pain is to provide some of the automated tools as well as assistance in adopting them," Spooner says. "We'll be significantly increasing the staffing among our nurse informaticists to be out there working with the physicians to help them think through the workflows."

Just tell us what we need to know

Documenting better can begin by discussing it differently as a matter of course, says Rady's Holmes. The 250 pediatric specialists who practice at the hospital speak a dense language of procedures and adhere to dozens of complex clinical pathways for treatment depending on key details of patient status. Educational efforts under its documentation improvement program emphasize getting to the exact point of the problem, one procedure at a time, and gradually replacing unspecific jargon with the right terminology, says Holmes.

By using the right terms in day-to-day conversation about a certain procedure, "they will eventually — hopefully — carry that over into other aspects of their specialty," he says. The upshot is, "We're actually teaching them ICD-10, though they don't realize they're learning it."

It all goes back to how physicians think about the patients whose predicament they document, Leach says. "They're trying to really create a story that gives context and social history and clinical data, and that's why they are sort of stuck with a narrative construct."

Information technology advances may render the narratives easier to deal with, but only if they get to the point. "I see lots of health records that go on for pages and pages and none of the key information is there," says AHIMA's Rhodes. That's why he recommends a general clinical documentation improvement effort to detect a pattern of data gaps now and target educational efforts on closing those gaps.

Preparation for ICD-10 is an exercise not in proliferation but in brevity — getting those extra few details from doctors, and not troubling them for anything but those few details, Rhodes says. "What's the one piece of information you need to assign the right code?"

Hospitals may be halfway there already if they've helped to create the right habits in their clinicians, says the AHA's Leon-Chisen. "There are some physicians who document well, and for them it will be a matter of just tweaking it to make sure that it's specific, while others may need a lot more work."

John Morrissey is a freelance writer in Mount Prospect, Ill.



Seducing MDs with quality data and analytics

The prospects for making doctors feel partnered rather than put-upon lie in the wealth of information that ICD-10 will store beneath the surface of the information technology terrain. Combining thorough data collection with insightful analysis and support for clinical decisions will be a key pursuit at Children's Hospital Colorado in suburban Denver, says Mary Anne Leach, its CIO.

"We need to make it relevant for the physicians so they can tell their story, but do it in a way that gives everyone the specificity needed to code correctly — and, obviously, correct codes mean better-quality data [and] analytics," Leach says.

"But the other thing we're trying to do with our docs is to give them a return. We're going to ask them to spend more time and put more thought and energy into their documentation. What I'd like to say is, 'If you're willing to partner with us in this way, we'll create dashboards for you using that data, we'll create reporting templates for you, we'll create decision-support rules from which you might benefit, we'll create a universe in our analytics environment so that you can do reporting.' We're trying to give them something back, because we know it's going to be an investment for them."

Somehow, in all the grueling, exacting efforts to match information reporting requirements to the proliferation of codes for diagnoses, conditions and procedures, hospitals have to get across that "this is the data we use for analysis, not just billing," she says. "That's the whole reason we're doing this. It's to have more granular data in the end, and we can't add more codes to ICD-9 … it's like running out of account numbers on your patient accounting system."

Children's is making use of tools available in an electronic medical record to build data dashboards integrated into the information storage layer. "To the extent that we can, we're leveraging [the] capability to present that data visually to physicians — and they respond to that. They want the best outcomes for their patients, they want to know how they compare with others in terms of outcomes and costs. So our return for them is going to be the data and the analytics."

An electronic medical record's decision-support capabilities also can address issues of documentation. "If it's a complex patient with a complex series of problems — and a complex coding scenario — perhaps those might be the times when we produce an alert that just says something like, 'We need these specific things documented in this note.'"

Though the ICD-10 issue is fraught with debate about responsibilities imposed on providers, forward-looking health systems can't let it devolve into that, Leach says. "This is not going to be another compliance mandate; that's not how we're approaching this. If we did, we would fail with the docs. This is really about quality of care, this is about good data, about helping them tell the story that they want to tell, and getting it right." — John Morrissey



Easier than it seems

Aids to documentation don't have to be state-of-the-art. Just figure out a convention that's meaningful for coders and easy for doctors. Henry County Health Center in Mount Pleasant, Iowa, is trying to establish a routine in which physicians mark on drawings the exact location of a problem. For example, for a finger fracture, "You look at the film and you know the finger's broken, you know it's between the middle knuckle and the end knuckle," says CIO Stephen Stewart. "All we're really asking you to do is record that it was the left hand between this knuckle and that knuckle."

When talking to one of his top doctors about buying into the ICD-10 conversion, Stewart says he turned the topic around to the physician's point of view. Here's how he summarized the conversation.

"Do you, as a medical practitioner, believe that more data allow for better conclusions and sounder medicine?"

"Yes, I do agree with that."

"Do you believe that the more granular that data is, the more meaningful it can become?"

"Yes, I do."

"Do you believe that more granular data, more meaningful data and better data can help produce better outcomes for your patients?"

"Yes, I do. Who could argue with that?"

"Well, that's really what this is all about."

The documentation challenge for ICD-10 is often about getting physicians into the habit of telling more about the patient's condition, but that conscientiousness actually is not always fostered within the ICD-9 environment, says the American Health Information Management Association's Kathryn DeVault. One example is simple repair of a blood vessel. No matter where it is, it's one ICD-9 code. The doctor can go on about its being in a finger, leg or chest, but "you don't even have to read the documentation" to pick the code. In ICD-10, there are upward of 200 codes for vessel repair — but the doctor only has to say where it happened, and just one code of the possible 200 is matched to it. Among other things, that now can affect the DRG and severity of condition.

In the era of accountability, ICD-10 concepts that don't exist in ICD-9 will help explain "why one patient gets readmitted and another one who has the same medical condition doesn't," says the AHA's Nelly Leon-Chisen. For example, medication can control heart failure, but if the patient doesn't take it or follows other instructions, that can't be reflected in ICD-9 other than generally coding "patient not compliant," she says. In ICD-10, "there is a brand-new concept called underdosing, when someone takes less of a medication than recommended." Providers can get specific about noncompliance with a certain category of drug or a diet regimen, and state reasons for the failure including confusion, forgetfulness or inability to afford the medicine. — John Morrissey




Address biggest needs first.

Start building general awareness among physicians right away, but analyze the relative scope of the documentation challenge by specialty and put resources toward those who will face the biggest job. Infectious disease specialists face only a 2 percent increase in codes to document. Orthopedists will have many thousands more codes: A sprained ankle goes from 4 to 72; a radiance fracture from 30 to 1,800.

Determine impact on payment.

The variable impact goes not only for clinician activities but for payment formulas, says Children's Hospital Colorado CIO Mary Anne Leach. "Based upon some of our payer contracts, the coding isn't going to matter as much as major diagnostic category, which we don't think will be much changed with ICD-10." Some contracts may pay a daily rate for a category. "A major diagnostic category may be 'heart.' But if we code this way in 9 and this way in 10, it's still 'heart.'"

Go with those ready to go.

When determining the priority order of ICD-10 technological assists, be mindful of groups of doctors that could be well-prepared for it, as well as those who might be hard to reach. "We clearly want to make sure that we're ready for those who are ready, and there may be some that are more difficult than others," says Sharp HealthCare CIO Bill Spooner. "It's tougher to get the surgeons, for example, than some others because they tend to be bopping from spot to spot."

Build in clinical improvement.

Doing coding concurrently with hospital activity instead of post-discharge can help prevent care slipups, says the AHA's Nelly Leon-Chisen. There may be nothing in the record to explain an abnormal lab finding, for example, and a documentation specialist can quickly inquire about it. "Is this something that the doctor saw and is acting on … or is it something that just slipped through because there were so many results, and so many different things the doctor may not have seen or may not have been notified about?"