The US healthcare industry has been grappling for too many years now with the implementation of ICD-10 medical codes. The new ICD-10 code set promises to improve the classification of the massive and growing reservoir of health information and to bring the United States up to the international standard for healthcare documentation.

There is no question that the US is lagging significantly in this vital health information area. Most other developed countries have long since adopted and implemented the new standards. The need for an upgrade to the current system was identified formally in the early 1990’s when the National Committee on Vital and Health Statisics affirmed that the current code structure was “broken”. The numerous delays in implementation since that time can be traced to a handful of short-sighted economic and political considerations. Regardless of the cause, the US healthcare system can ill afford additional delays. The quality and integrity of health data in the US has been declining for several decades now.

The deterioration of health data can be blamed in large measure on the fact that the US has simply outgrown the ICD-9 medical coding system. While ICD-9 served the industry adequately for a number of years, the growth in medical procedures, treatments, diagnoses and technology have surpassed its limited adaptive capability. The universe of available ICD-9 codes is rapidly dwindling and certain code sets are becoming oversubscribed. This is resulting in tremendous inefficiency and is calling into question the integrity and completeness of the data delivered through the system. As the risk of compromised patient care increases, the need for change is becoming more obvious.

Advantages of the ICD-10 Medical Code Classification System

Implementation of the ICD-10 medical code set will confer a number of significant advantages on the industry. These include:

1. Greater specificity and accuracy in healthcare documentation
2. Reduction in manual intervention arising from the limited descriptive capability of the existing code set
3. Increased level of detail in the final health record
4. Improvement in care decisions with elevated data quality
5. Reduction in errors and quality assurance activities
6. Reduction in reimbursement holdups due to inadequate information or clarity
7. Increased productivity of coding practitioners as automation becomes more applicable throughout the entire process
8. Increased compatibility with other global health information systems
9. Improved patient outcomes

Conclusion

While there are certainly some compelling economic costs associated with full adoption and implementation of the ICD-10 code set, the costs of non-adoption are growing every day and threaten to dwarf real implementation costs. Additionally, the negative impact on patient care will increase exponentially as the existing data model becomes less stable. The evidence for successful implementation is readily available. Virtually every other major developed country in the world has successfully adopted ICD-10. The time for discussion and analysis is past. The time for bold action and implementation is here.

Healthcare documentation has come a long way. A continuous stream of technological advancement and automation has generated significant gains in efficiency while increasing the quality of care through improved access to vital patient information. The future looks bright indeed, as incremental improvements in technology promise to confer additional benefits. Many health care providers are embracing new versions of technology as quickly as they are rolled out in the hope of delivering heightened levels of patient care at a lower cost.

Nowhere are the advances in technology felt more keenly than in the healthcare documentation arena. For many years, medical records departments have been viewed as cost centers and subordinated to other seemingly more important areas of the healthcare organization. As a consequence, healthcare documentation has historically received neither the glamour nor the funding that other front office and patient care activities have enjoyed. Over the past few decades, however, the balance of power has begun to shift. Healthcare documentation is now rightly seen as one of the keys to profitability and a catalyst for industry growth.

New talent and resources are beginning to flow into this area breathing new life and vitality into what was once an afterthought in most healthcare organizations. Leading the charge is a new breed of profit minded executives set on transforming the healthcare model. As the industry ushers in a new era of efficiency and profitability, decision making executives would do well to remain aware of some of the significant risks of an overly ambitious technology adoption timeline. For instance:

Underdocumentation

The risk of underdocumentation has the potential of increasing dramatically with new electronic medical record (EMR) protocols. That EMR technology promises to exponentially increase efficiency in some aspects of care – primarily by decreasing administrative workload and increasing the speed of information flow – is not in dispute.

However, it should be recognized that the rapid adoption of this technology in its current form has the potential to create down- stream issues with patient care as a result of improper or inadequate documentation. EMR threatens to increase costs as inadequately documented assessments and activities are reworked. Patient care may also be compromised as diagnoses are delayed due to lack of complete information flow.

Underexamination

EMR’s may steer physicians to point and click their way through a few standard procedures, potentially ignoring less obvious, non-charted options.

Undervaluing the traditional role of the physician

As technology asserts itself with fits and starts into the patient care process, there is a real risk that the transition from physician directed outcomes to technology driven outcomes will be too abrupt, again compromising patient care. Additionally, recent studies suggest that the physicians spend about 9 times longer entering an equivalent amount of information via EMR and EHR than with traditional dictation based narratives. Time is money, and physician resources are far too costly to be assigning tasks better handled by non-physician professionals.

Chronic under reporting

Pushing physicians in a direction of drastically less documentation when the trend has been toward greater documentation of patient care for the past several decades is at best imprudent and at worst reckless. While some efficiency in healthcare documentation may be good and necessary, it is simply unrealistic to expect a physician to render what has historically been a multi-page detailed medical record document with a few clicks of a mouse.

Undervaluing the role of the medical transcriptionist and medical record technician in the records process

Speech recognition has made some significant strides in recent years and now plays an increasingly prominent role in the healthcare documentation process. However, it has still not proven to be as effective as a seasoned transcriptionist in rendering a dependable output – particularly when it comes to some of the more complex documentation tasks. There are simply too many variables that require human intervention to achieve consistently accurate and completely automated documentation with today’s technology. While it seems clear that the role of the traditional medical transcriptionist will be forever transformed by new advances in technology, there will likely always be a role, and I trust, an increasingly important role, for the professional medical records technician.

Conclusion

As technology continues its steady march, there is no doubt that it will continue to encroach on traditional methodologies and bring a new and important measure of efficiency and profitability to the healthcare industry – benefiting patients and practitioners alike. Those organizations that are careful and thoughtful in their implementation strategies will tend to have smoother transitions and will likely manage their risk more successfully than their more zealous counterparts.