Halamka focusing on meaningful data in ICD-10 effort

WALTHAM, MASS.--It’s not the new codeset of ICD-10, it’s getting meaningful data into the new codes that concerns John Halamka, MD, CIO of Beth Israel Deaconess Medical Center (BIDMC) in Boston, speaking at the Massachusetts Health Data Consortium’s March 10 conference on ICD-10 implementation.

Halamka also said he is concerned about being “audit-proof” when recovery audit contractors come. It will be “bounty hunters’ delight as they find the disconnect between what we actually documented and what we coded. That’s the technical dilemma.”

BIDMC has a variety of self-built and purchased systems. It’s relatively easy to control front-end retrofitting of self-built systems but the niche, departmental systems concern Halamka the most because “there are so many downstream systems that have yet to be retrofitted. They are not mission critical but what are you going to do come Oct. 1 if your registries can’t be populated?”

BIDMC has 146 different systems that have to be modified and fully tested for ICD-10, he said, to ensure that physicians will get the right code out to the billing agency.

Halamka said he has had no choice but to double his coding staff because “we have assumed that we will have a 50 percent reduction in productivity and that’s not short term—that’s a forever expense.” This comes at a time it’s nearly impossible to hire and retain coders, he said, because contract firms lure trained coders away from organizations with more money. So far, BIDMC has not resorted to offshore coding but he expects to in the future to “supplement some of these workflows.”

He also hoped to implement computer-assisted coding and clinical documentation improvement (CDI) and, while there are “some bleeding-edge software applications that do CDI in real-time, we judged none of them mature enough to put them in our ICD-10 timeline. We will do that after Oct. 1.”

To remediate all its systems, Halamka announced a “code freeze” last August, which would go from October through the end of February. That period allowed them to “focus entirely on ICD-10 without distraction.” The freeze did not make him and his team popular with the rest of the staff since a lot of projects were deferred. “We are now about to release the systems back to users after all clinical and financial remediation.”  

As of initial testing results, “we were passing 835s successfully. So far so good. We can mechanically pass a code but whether the code is accurate, relevant or auditable--that’s a totally different problem.”

BIDMC has been working with Systems Evolution to maintain the ICD-10 transition. “It’s been well-documented that certain clinical areas are going to be up a creek without a paddle because of the code explosion,” said Matt Walton, PhD, principal consultant.

He’s been helping the hospital system build an electronic system which “is not always an easy sell.” The code explosion, however, does not affect everyone in the same way so there’s no need for a blanket approach, he added.  ICD-10 has been a convenient driver to move to an electronic system which is a good thing because it allows for greater flexibility, search functionality and greater options for physicians in how they select the codes they need.

To get the electronic system up and running, Walton has been talking to chiefs of staff to get their buy-in. “They know paper is untenable going forward. We’re trying to make the transition as painless as possible.” The hope, he said, is to have the system running in the ICD-9 environment in June to allow physicians “ample opportunity to get used to the system. The last thing we want is to give them a double whammy on Oct. 1. Introducing the electronic billing system early is paramount.”

Governance is an important part of the ICD-10 implementation process, Halamka said. Monthly calls bring together the executive committees from each of the “moving parts,” including other hospitals and the physician organization. The medical staff steering committee made ICD-10 training a condition of practice. Everyone needs very focused training, he said. “You can build or buy training materials and we’ve done both.”

BIDMC has been working on ICD-10 implementation for two-and-a-half years, including a complete redesign of workflows and retraining of every physician, nurse and member of business teams. The original ICD-10 regulations estimated an organization like BIDMC would need to spend $600,000 to successfully make the transition. Halamka said he has spent about $5 million and expects to reach about $8 million before the effort is complete.

One of the most surprising realizations has been the fact that the hospital’s leadership sees federal mandates—Meaningful Use, ICD-10, HIPAA—as irritations and distractions and want to get back to doing “real work,” Halamka said. But, “if 60 percent of the hospital’s revenue cycle is at risk don’t you think that should be declared our real work?”

Rather than just working to meet the Oct. 1 implementation, Halamka said “ICD-10 is the gift that keeps on giving. ICD-10 has to still be on the docket as one of our major projects” for some time to come.