The Perfect Storm Barometer: Which type of precipitation carries the greatest risk for clinicians?

Pundits have been predicting the perfect storm for the last few years. This refers to the confluence of clinical and administrative practice impacts of the change from HIPAA X12 4010 to 5010, the CMS Meaningful Use incentive program, and the change from the diagnostic coding system ICD-9 to ICD-10 in the U.S. Other changes are also in the background such as electronic prescribing of controlled substances (DEA) and changes in the regulation of EHRs and medical devices (FDA.) These initiatives will impact all practices ranging from those in the largest integrated delivery networks to the solo provider. The greatest effect will be on small practices because they generally do not have an abundance of resources and highly trained experts needed to fulfill the new requirements. The migration, already underway, from small practices to much larger groups and employed positions is likely to become a stampede. Retirement will be a course some will choose that could worsen the physician shortage in the U.S. So if there are limited resources, how does one deploy available resources now?


The Arizona chapter of HIMSS, the Arizona chapter of AHIMA, the Arizona Regional Extension Center, and a number of other organizations sponsored an educational session about ICD-10 last Friday. We learned that the U.S. is the last major western country to make the switch. Asian countries including China, Korea, and Japan among others have already made the change. You might wonder why the change to ICD-10 is being brought up now if it isn't even scheduled to take effect until October 1, 2013. Aren't there more pressing items? For example, the hospital where I work published an information sheet this month about the ICD-10 transition. Information technology staff recommended a 3 to 6 month period for training. What their message failed to convey was the need for a substantial risk-based analysis of current state, planned changes, gap analysis, need to coordinate software and hardware updates in multiple systems, implementation testing, increased staffing needs and productivity loss across the spectrum of the organization.


Experience in Canada and Australia showed a 10-50 percent loss of productivity of clinicians and coders that lasted up to a year. In many cases, productivity never returned to the condition before the changeover. The reasons are that ICD-10 has much more specificity than ICD-9. There are also many more codes for both diagnoses and procedures. That means that coding staff are going to need to be much more knowledgeable in anatomy, physiology, and the differences between similar sounding surgical procedures. Clinicians are going to need to document their work much more thoroughly than most have been accustomed to doing in the past or risk denial of claims and/or reductions in payments. All of this will take everyone more time. It is a scary thought but clinicians should probably plan on a 25% reduction in practice income for 6 months to a year.


Useful risk mitigation strategies are: educate yourself about the coming changes-early and frequently, communicate with all your vendors and work collaboratively to install and test all systems involved in the changeover well ahead of Oct. 1, 2013, plan coding scenarios to test coder and clinician readiness, plan to accommodate the loss of productivity and income. Technical solutions such a computer assisted coding have promise but are not ready for routine widespread use. Having a certified EHR will make it easier to collect and code patient data needed for ICD-10 but many systems will need to be upgraded. Consider whether Meaningful Use or ICD-10 compliance is more important in deciding on how you deploy your limited resources. I know one consultant who thinks that ICD-10 should be the priority because it poses the greatest risk to the financial health of a medical practice.