ICD-10 Extension and more

Starting a Health Information Foundation

2009-07-01T06:26:00.000-07:00

In the 30 June 09 post I suggested each of us find a personal health record framework and start building a record. (What if every hospital taught about a PHR as part of pregnancy instruction? What if every newborn received, alongside a blanket, a "bunny-suit," and a pacifier, a PHR with data? For every subsequent well-baby follow-up there would be new data for her/his PHR; a wellness habit is formed.)

Start teaching about PHR in primary or secondary school health education classes, assigning the building of a PHR alongside learning how to find credible health/medical knowledge from the web. Other points of fellowship where PHR can be introduced include public libraries, shopping malls, grocery stores, and senior citizen centers.

myPHR lists the steps to take for staring your PHR. Your medical information is as personal as it gets; protect it and maintain confidentiality. Let trusted family members know that you are compiling it, and where you keep it, but beyond that, keep it safe and protected.

♦ one- make a checklist of each of your doctors’ offices or the medical records staff at each facility where you have received treatment. After you have contacted each one, checkoff the name with a date you can expect the record to be available. Most providers and facilities charge for paper copies; ask if the record can be provided as a text file.

♦ two- ask for an authorization for the release of information form.
Complete the form and return it to the provider or facility as directed.

♦ three- while you wait for the information you want, find a PHR- either a software program for your computer or a web-based PHR. (Most, but not all, web-based PHRs are free.) Use a manila file folder to keep any paper records in one place.

♦ four- copy & paste the data from your text file medical records into your PHR. Type in the information from your paper medical records. This is tedious, but should not be rushed "just to get it done." Type accurately so your PHR will be a useful tool years later when you have forgotten details. In some medical cases, details are life-saving.

♦ five- use a USB drive or other record to bring your PHR with you to every medical appointment so you have the information with you. After an appointment, update your PHR with entries from providers, yourself, or your family member.

myPHR has laid a solid foundation for building a useful PHR. As usual, the real work is the responsibility of the individual. Each of us has to make an effort like this in order to reform the "big picture" of health care.

Personal Health Record is the foundation

2009-06-30T07:52:00.000-07:00

One massive stumbling block to wide-spread adoption of electronic health and medical record systems by providers and health systems is the lack of a positive "market force." CMS is pushing electronic data transfers and records with deadlines and potential for reduced reimbursement payments for non-compliance.

In the face of dozens of politicians clamoring for immediate adoption of HIT and even more vendors of EHR/EMR devices and systems making claims like the "miners 49ers" of more than a century ago, there is no clear "landmark" by which providers, health systems, and consumers can make decisions about what system to put to work.

An online poll- number and demographics of respondents unknown- at myPHR (an American Health Information Management Association web site) reveals about keeping health information-

♦ Not at all 7%
♦ On a flash drive or memory stick 37%
♦ On my computer 14%
♦ Through an online service 2%
♦ Loose leaf binder or paper file 38%.

If 100 people chimed in, 98 have some degree of HI and that "file" is essentially unuseable by a provider. No provider will make time to futz with attempting to decipher such "files;" time is not a luxury a provider has.

The casual poll emphasizes one effort every individual should consider making: starting a personal health record (PHR). AHIMA also has a link-list of 78 or so PHRs for us to investigate and select from.

Only through personal responsibility and effort to covert our paper-based medical records to an electronic form can we realize any benefits from health information technology. Once our data is immediately useable by a provider, s/he can begin to
♦ prevent bad medication interactions
♦ limit medication side-effects and
♦ better understand a patient's comprehensive medical history.

2009-06-29T17:34:00.000-07:00

Google bets on mobile market, July 31, 2007
♦ "Mobile is the fastest and cheapest way to reach the largest number of people," said Chris Sacca, head of special initiatives at Google.

"There are billions of people on this planet who still don't have access to the Internet. And we think mobile presents the biggest opportunity to get them on the Internet."

[If one didn't know better, one would think Mr. Sacca was talking about embracing PHR, EHR, and EMR systems.

Required med student IT
Third Year Medical Student PDA Requirement, University of Virginia Office of Medical Education

♦ "Personal Digital Assistants (PDAs) are useful tools in a variety of clinical settings. As an extension of your desktop or laptop computer, they provide quick access to reference materials and medical applications."
♦ Apple iPod Touch 8 GB; SmartPhone: Apple iPhone 3G 8 GB
♦ Students may use a Palm TX, Palm OS Centro or Treo 755p smartphones. All the major medical software packages are available for these devices.
♦ The School of Medicine has a portal specifically for use by PDAs and other Mobile Medicine devices.

The Palmdoc Chronicles- The latest Medical PDA News and Updates, posted March 2009- "PDA choices for medical students"

♦ There are really only 3 choices left for PDAs and it is really a personal decision which platform one prefers as each has its own strength and weaknesses.

In no particular order:
♦ iPod Touch
♦ Palm TX
♦ HP iPAQ 111 Classic Handheld.

Familiarity breeds benefit
"New Tool in the MD's Bag: A Smartphone," by Sindya N. Bhanoo

Steven Schwartz, often encounters patients who have no idea what each of the pills they've been popping is called. "But usually they can tell you what it looks like," the Georgetown University Medical Center family practitioner said. "They might say it's a blue, triangular pill for hypertension."

Armed with an iPhone, Schwartz is able to play detective. He uses an application
called Epocrates to input pill characteristics, such as color, shape and clarity. The software replies with a list of medications and images that match those criteria, allowing him to deduce what the patient is taking.

Schwartz says his iPhone has become indispensable....

♦ Special to The Washington Post; Tuesday, May 19, 2009

Always on continuing education
"Will docs get their CME credits on iPhone?" by Marc Iskowitz, July 10, 2007; Medical Media & Marketing

♦ Unbound Medicine president and CEO, Bill Detmer, MD, said the iPhone, like other wireless devices, enables doctors and nurses to carry medical knowledge "wherever they roam."

"Why Google's software approach won't work for smartphones or the enterprise,"
Posted by Jason Hiner, June 29th, 2009 opines

"... smartphones require something different. They demand meticulous attention to the end-to-end experience of the user. To accomplish that, a company needs tight collaboration among all of the engineers working on the project, plus a disciplined management process to coordinate all of the details."

[Mr. Hiner might have been addressing the designers, developers, and manufacturers of EHRs, EMRs, and PHRs as well as addressing CMS, HHS, and the Office of the National Coordinator of HIT on how to best incorporate college and technical institute IT expertise in implementing electronic protocols (5010), devices, systems, and networks.]

"The other big problem for most smartphones is the hardware/software split. The result is software that is built for lowest common denominator of devices, and that makes those devices far less intuitive and usable than devices and systems where the hardware and software are tightly integrated."

[Not only is there a hardware/software split, there is the additional split from real-world clinical workflows; the classic theory vs. reality. A split has become a gulf that has to be bridged by some providers as early as January 1, 2012.]

"to succeed in smartphones and business applications then it’s necessary to havededicated teams/departments that are much more process-oriented and focused on product quality from end-to-end."

[If Mr. Hiner had added "clinical" to "process-oriented" and replaced "product" with "patient care," he would have produced a framework for building useful and workable HIT systems.]

ICD-10 Preparation Checklists and Primer

2009-06-25T16:55:00.000-07:00

ICD-10 preparation hecklists are frameworks for thorough planning, discussions, and designing long before money has to be spent on consultants and health information technolgy (HIT). Use a checklist or waste time and money. "Failing to plan is planning to fail."

♦ implementation deadline date– October 1, 2013

Checklist links
CMS ICD-10 Overview, 70-page PDF/PPT includes links to AHA, AHIMA, CDC, CMS

Ingenix version

American Health Information Management Association (AHIMA) version

"It is not too early to begin planning for the transition from the Ninth revision to the Tenth; there isn’t much time for putting those plans in motion."

♦ Authors Sue Bowman, RHIA, CCS and Ann Zeisset, RHIT, CCS, CCS-P

Since the notice of proposed rule-making (NPRM) has been published establishing the timeline and expected implementation date, educate all people in the target audiences on key requirements of this rule.

Bowman and Zeisset developed for AHIMA a checklist for a phased approach to implementation. The four phases are
♦ Phase 1– Impact Assessment [daunting details]
◊ four major tasks
◊ target audience (16 groups)
◊ goals (13 primary, four sub-goals).

♦ Phase 2– Overall Implementation
◊ three major tasks
◊ target audience (seven groups)
◊ goals (seven primary, six sub-goals).

♦ Phase 3– Live use preparation
◊ six major tasks
◊ target audience (six groups)
◊ goals (five primary, two sub-goals).

♦ Phase 4– Post-implementation (HIT forensics)
◊ four major tasks
◊ target audience (eight groups)
◊ goals (eight primary, three sub-goals).

AHIMA ICD-10-CM Primer

This AHIMA web page describes ICD-10-CM and –PCS as providing "the level of detail needed for morbidity classification and diagnostic specificity. Both also provide code titles and language that complement accepted clinical practice."

♦Authors Ann Barta, MSA, RHIA; Gale McNeill, RHIA, CCS; Peggy Meli, PhD, MS, RHIA, LHRM; Kathleen Wall, MS, RHIA; and Ann Zeisset, RHIT, CCS, CCS-P.

Sections include
♦ Comparing ICD-9-CM and ICD-10-CM
♦ Code Structure of ICD-10-CM versus ICD-9-CM
♦ ICD-10-CM Structure
♦ Differences between ICD-10-CM and ICD-9-CM
♦ Organizational Changes
♦ New Features
♦ ICD-10-CM Code Examples and
♦ Learning the ICD-10-CM System.

AHIMA recommends downloading the
♦ ICD-10-CM index
♦ tabular
♦ guidelines and
♦ general equivalence mapping files
General Equivalence Mappings (GEMs) are crosswalks between the -9 and -10 code sets; GEMS may be a major challenge to ICD-10 implementation.

These are on the National Center for Health Statistics or the CMS ICd-10 Overview websites.

AHIMA also recommends
♦ improve your clinical pathophysiological and human anatomy knowledge "to be more prepared for ICD-10"
♦ learn the physiological mechanisms of diseases and treatments
[One title is Clinical Pathophysiology Made Ridiculously Simple by Aaron Berkowitz.]

New codes brings changes

HHS also mandated adopting new standards for electronic transactions essential to use the ICD-10 system. HIPAA transactions 5010 is replacing the 4010 version.

♦ implementation date– January 1, 2012

ICD-10-CM and ICD-10-PCS are replacing the ICD-9-CM code set.

♦ there are very few 1:1 crosswalks (General Equivalence Mappins) because of the greater number and specificity (anatomical, pathophysiological) of –10 codes compared to –9 codes. The following links land on details about GEMs
CMS document
CDC document
AHIMA document

The new ICD-10 code system has more than 155,000 codes to accommodate advances in diagnoses and procedures and will represent significant changes for
♦ practicing physicians
♦ hospitals
♦ third-party payers
♦ business associates
♦ clearinghouses and
♦ software vendors.

Anesthesia site could have been microPHR

2009-06-24T07:21:00.000-07:00

Modern Healthcare's daily IT e-newsletter HITS reported by Jean DerGurahian / HITS staff writer, in its Monday, June 22, 2009 issue-

The American Society of Anesthesiologists launched a new Web site to serve as a resource for patients.The site, Lifeline to Modern Medicine, provides information about
♦ anesthesia care
♦ how patients can help prepare when they are undergoing medical procedures
♦ different types of anesthesia
♦ what to expect before and after surgeries and
♦ information about relevant medical specialties.

Lifeline to Modern Medicine is a well-designed site. The destination of each tab-link is one page of concise information. (FAQs fill three pages.) Lifeline can be followed on Twitter.

Navigation tabs at the top of the pages lead to
♦ Home
♦ Who is an Anesthesiologist?
♦ Types of Anesthesia
♦ What to Expect
♦ Patient Stories
♦ FAQS
♦ Medical Specialties.

A right-column sidebar has a a checklist (one-page PDF) patients can print and fill out with their medical history, medications and allergies to have ready in case of surgery.

[Electronic records and data-keeping are at the top of the HIT "heap," yet the checklist is for printing out! LIfeline could (Is "should" too strong?) have made an XHTML form using an limited data set standard for the site visitor to complete, save the data file, then print the styled PDF form. The visitor could have been eased into a tiny, easily-understood, manageable PHR. No fuss, no muss. We must think electronic concurrent and simultaneous with paper to overcome the pain of changing.]

Successful pattern for health info tech regional extension center

2009-06-23T16:10:00.000-07:00

In the Federal Register, May 28, 2009 (Volume 74, Number 101), the Department of Health & Human Services proposed the creation of Health Information Technology Regional Extension Centers.

HITRECs need not start with a blank slate, but can use the USDA Cooperative Extensive Service (CES) as a model for delivering immediately useful knowledge to people, um, "in the field."

A bit of history about the 95-year success of technology transfer by CES gives evidence of its viability as a model.The Morrill Act of 1862 established land-grant universities to educate citizens in agriculture, home economics, mechanical arts, and other practical professions.

Extension was formalized in 1914, with the Smith-Lever Act. It established the partnership between the agricultural colleges and the U.S. Department of Agriculture to provide for cooperative agricultural extension work.

At the heart of extension, according to the Morrill Act of 1862, was:

♦ developing practical applications of research knowledge
♦ giving instruction and practical demonstrations of existing or improved practices or technologies in agriculture.

By analogy, health information regional extension centers (HITRECs) assist health care providers gain "meaningful use" of IT to

♦ improve the safety and quality of health care
♦ better understand and manage valuable medical and health data
♦ reduce clinical workloads through workflow analysis and
♦ effect common-sense clinical process modification or redesign.

("Meaningful use" is not yet clearly defined and will affect the selection of HIT and the features sought.)

Using that model, the same principles in the context of health care form the heart of health information technology extension work. With this proven history of successful agriculture technology and expertise transfer [The U.S. didn't become "the breadbasket of the world" by accident] as guidance, HITRECs can tap, for technology and practices that are relevant to health care providers, resources such as the

♦ National Institutes of Health (27 different Institutes and Centers)
♦ Centers for Disease Control & Prevention Coordinating Centers/Offices
♦ National Institute of Standards & Technology (Information Technology Laboratory) and
♦ Federal Laboratory Consortium for Technology Transfer (more than 250 federal laboratories and centers) as well as
♦ schools from MIT to Stanford, from Lake Area Technical Institute to Caltech.

HITRECs have a "running start" with the Morrill Act principles and county extension web sites on how to deliver clinical, medical, and science research knowledge regarding

♦ ANSI 5010 and ICD-10 implementations
♦ electronic record systems (PHR, EHR, EMR)
♦ therapies (e.g. anodyne and proliferative injection)
♦ clinical trials
♦ pharmaceuticals
♦ aspects of evidence-based medicine
♦ medical devices and
♦ wellness.

"The journey of one thousand miles begins with but one step." Or, from a different persepective- "The cost of initially solving a problem is $1. Solving the same problem many times removed downstream is $400 or more." Choice and the consquences of choice.

Health information tech is "distruptive technology"

2009-06-22T17:01:00.000-07:00

The description for a Harvard Business Review article reprint of "Disruptive Technologies: Catching the Wave;" Jan 1, 1995, offers fundamental thinking- and strategy- to healthcare providers and management in the implementation of ICD-10 and health information technology (HIT).

In the context of patients, patient care, practices, and facilities, "Catching the Wave" is a primer on HIT pro-action and preventing sleepless nights.

One of the most consistent patterns in business is the failure of leading companies to stay at the top of their industries when technologies or markets change. Why is it that established companies invest aggressively- and successfully- in the technologies necessary to retain their current customers but then fail to make the technological investments that customers of the future will demand?

The fundamental reason is that leading companies succumb to one of the most popular, and valuable, management dogmas: they stay close to their customers. To remain at the top of their industries, managers must first be able to spot disruptive technologies.

To pursue these technologies, managers must protect them from the processes and incentives that are geared to serving mainstream customers. And the only way to do that is to create organizations that are completely independent of the mainstream business.

Perhaps the health care practice or system may elect to form its own HIT (Health Information) Unit in collaboration with other practices and computer information systems departments at technical institutes. Pooling medical and technical expertise may streamline implementation efforts such as workflow analysis and specifying requirements.

Healthcare providers are confronting the disruptive technology of HIT. Electronic health, electronic medical, and personal health record systems will, if the politicians have their way, largely replace paper as the primary documentation medium. Concurrent and simultaneous implementations of two additional disruptive technologies- ANSI 5010 for Health Insurance Portability and Accountability Act (HIPAA) transactions and International Classification of Diseases, Tenth Revision (ICD-10) undoubtedly will test the resourcefullness and patience of professionals in information technology as well as in healthcare.

Every computerized medical record system has to accommodate documentation regulations in order to satsfy

Joint Commission on the Accreditation of Healthcare Organizations
HIPAA
third-party payer
medico-legal and
regulatory stipulations.

Doctors, nurses, and health organization managers who have these systems have no option to merely "plug and play" the tools.

Fundamentally, they will have to learn technical, workflow, and regulatory details of HIT in order to even open the door to practice medicine. The Centers for Medicare and Medicaid Services have given providers an ultimatum (Ingenix):

Health and Human Services (HHS) released the final rule for implementing the 5010 transaction standard for health care claims, and version D.0. for pharmacy claims. The final rule indicates that trading partners have to be ready to exchange 5010 transactions starting December 2010 and can ONLY exchange 5010 transactions starting January 1, 2012.

Covered entities

health plans
health care clearinghouses and
certain health care providers

must use 5010 in electronically conducting certain health care administrative transactions, such as claims, remittance, eligibility, claims status requests and responses, and others.

The "must use" date for ICD-10 coding is Oct. 1, 2013.

Abstracting data from EMRs

2009-06-18T15:40:00.000-07:00

Soarian Quality Measures is data analysis software designed for extracting quality measures from electronic patient records. The software extracts and combines structured (database, spreadsheet) and unstructured patient data (word processed text, image captions). SQM reduces the time needed to comply with CMS and Joint Commission quality requirements.

Great speech-to-text capability is sorely needed.

One risk in rushing to adopt health info tech

2009-06-18T07:35:00.000-07:00

A Melamedia Coordinating EHR Incentives with HIPAA seminar warns "Failure to coordinate EHR adoption with mandated HIPAA electronic upgrades may end up costing adopters much more than the new incentives."

The most glaring example of the risk: HIPAA transactions (ANSI 5010) must be upgraded by Jan 1, 2012, and ICD-10 coding must be used by Oct 1, 2013.

The danger is that organizations - lured by the federal money - will rush to install EHR systems by 2011 with little or no thought as to how those systems will function with their other computer systems.

In Transitioning to ICD-10-CM/PCS— An Academic Timeline, AHIMA
ICD-10-CM is an alphanumeric diagnostic coding system containing 68,065 codes (14,025 diagnosis codes in ICD-9-CM).

ICD-10-PCS is an alphanumeric procedure classification system used for inpatient hospital settings only. It contains 72,589 procedures codes (3,824 ICD-9-CM procedures codes).

Seven characters, alpha or numeric, in the medical and surgical section carry the following meaning, in order: section, body system, root operation, body part, approach, device, and qualifier.

16 sections are coded for specific to types of procedures that are performed; the World Health Organization (WHO) lists 22 chapters that classify diseases and other health problems .