3/13/12 - Interview with Silvia Senes, "Misconceptions on Your ICD-10 Conversion"

Today we're featuring an interview focused on ICD-10 Conversion with Silvia Senes, an expert in transformational change in healthcare.  Her bio appears below:

Silvia Senes has held multiple positions with Canadian health systems and hospitals, including serving as Deputy CIO at both Saint Boniface General Hospital (the second largest health care facility in Manitoba) and later with Health Science Centre (the largest health care referral, teaching, and research facility in the Manitoba eHealth system).  In her experience in Canada, Silvia has hands-on experience leading ICD-10 conversions -- transformational projects that spanned multiple years.  A native of Buenos Aires, Argentina, Silvia holds over 15 years of experience as an IT leader in healthcare settings, leading transformational change such as EHR/EMR, ICD-10, and enterprise project management.  She now lives in Atlanta, GA, with her husband.

Silvia, you have a very unique background in that you have already led large ICD-10 conversion efforts during your time working in Canadian health systems.  What is the single biggest misconception you see right now in the U.S. as it relates to the ICD-10 conversion effort?

In one word: effort. When discussing with different groups the effort that is required for a successful ICD-10 conversion I have seen two extremes. On one end are organizations considering that the effort required to achieve a smooth migration to ICD-10 is minimal, so they are delaying the start of the initiative; and on the opposite end, there are organizations overwhelmed by the prospect of the migration and therefore resisting the change.

Organizations that minimize the effort required to successfully migrate think that the change will only affect Health Information Management, so they believe it is a contained effort. Their solution is usually minimalist and it only encompasses upgrading their coding system and training the coders on the new software. This group lacks the understanding of the width and depth that the change to ICD-10 brings and how it is really going to affect their organization, including anyone involved in clinical areas and revenue cycle.

On the opposite end of the gradient, you find the group who is resisting the change. These people do not see the benefits and opportunities that the change can bring to their organizations and the U.S. overall; so they don't see the ICD-10 conversion as a priority. They are overwhelmed by the sole thought of embracing this initiative and only considering the effort required for the conversion to ICD-10 and, not taking under consideration that this conversion is a step in the right direction, impacting the success of other initiatives already under way, e.g. EHR, Accountable Care Organizations, and meaningful use.

What organizations need to understand is that although the ICD-10 conversion is a significant venture, it is manageable. The key to success is having a talented group managing the initiative with support from the Executive team. This initiative needs to be a priority, as it has the potential to negatively affect the bottom line.

The health IT news publications have a lot of articles coming out right now, maybe as part of the HIMSS 2012 conference that recently wrapped, debating the issues on the ICD-10 conversion deadline being moved out to a date not yet determined.  What do you think about this further delay?

The need to replace ICD-9 and migrate to an improved coding system is not going to disappear. If anything, it is becoming a more pressing issue as the need for high-quality healthcare data is even greater now due to other initiatives (e.g. EHR, meaningful use, payment reform, ACOs).

Another point to consider is that a newer version, ICD-11, is due by 2015 as announced by the World Health Organization, and an alpha draft is already available. So we need to ask ourselves if the U.S., being the only developed country still using version 9, can wait until the release of version 11. In my opinion, the answer is no.  Delaying the move will only punish those organizations who have done due diligence by including the ICD-10 migration in their roadmaps and understanding impacts, benefits, opportunities and risks. All other projects which were identified as a dependency of ICD-10 will have to be either delayed or reworked, impacting budgets and timelines.

You've mentioned to me before that the single biggest impact on hospitals in the ICD-10 conversion is a possible drop in reimbursement due to the significant impact on the productivity of coders with the new system.  Will you elaborate on this for our readers?

As a result of the conversion to ICD-10 in Canada, there was a significant loss in productivity comparing pre and post ICD-10 levels. This was also the experience in other countries such as the UK and Australia. It was observed that there was a pronounced drop in coding efficiency for the initial 6 months, with post ICD-10 levels never returning to the ICD-9 levels.

There are several reasons for this loss of productivity happening. The initial decrease in productivity (for the first 6-9 months after the conversion) could be attributed to a steep learning curve. Coders need to incorporate knowledge of not only over 140,000 new codes, but also anatomy, physiology and medical terms, and physicians cope with new requirements involving documentation specificity and quality.

During this period it is expected to see a backlog and payment delays caused by errors anywhere in the data flow, resulting in required re-work for denied claims, adjustments and pending claims, and coders directing an increasing amount of queries to physicians when documentation is not adequate to support the higher level of specificity required with ICD-10.

After the initial period of the ICD-10 launch (close to the 12 month mark), we observe productivity increases, although never reaching the pre ICD-10 levels. The workload of coders and physicians has increased, as physicians have more information to enter in patient records and coders have more information to review.

A significant investment in organization-wide education and training are critical to reducing the impact ICD-10 will have on the organizations.

What do you think are the major findings for a hospital or health system after performing a readiness or impact assessment on ICD-10 conversion? 

Most organizations will be shocked when presented the results of a readiness and impact assessment. The one phrase that I recall hearing over and over again was "Are you telling me that ALL these groups and systems are affected?" This is the first step to really understanding how this initiative will affect their organization.

After performing an impact assessment, including operational, technology, and personnel readiness, key findings usually include:

  • The total implementation will require a high number of personnel hours, including education
  • The conversion will directly impact a diverse group, each of them needing customized education and training based on requirements and level of impact
  • External resources will need to be hired to support the work of internal resources
  • All clinical decision support will need to be updated, including templates, documentation, and policies and procedures
  • A project management organization (PMO) is necessary to manage the various work streams impacted and ensuring a smooth transition
  • An awareness campaign and a steering committee are required to assist in change management and gaining user acceptance across the organization
  • High number of systems affected
  • Cost implications, productivity loss and gaps
  • The need for parallel coding (coding records in both ICD-9 and ICD-10) for a period of time

What should these facilities specifically be concerned about?

Organizations should be concerned about not taking the right steps to becoming compliant by the deadline. These include conducting assessments to identify gaps and opportunities, planning a roadmap, ensuring an effective and efficient project management team, education and training, partnering with vendors, ensuring payer implementation plans are in place, and raising awareness. Don't underestimate the scope of what ICD-10 preparation can do for your hospital.

The main consequence that organizations that do not properly manage the conversion will face is a negative effect on their cash flow.

From a project management perspective, what do you think a reasonable timeline is for a hospital to successfully complete its ICD-10 conversion?  (You can't say "it depends.")

The answer to this question is based on the findings of a readiness assessment and gap analysis. There is no cookie cutter solution that will work for all organizations, as each organization has unique needs and culture. One of the variables that we need to consider and is often forgotten is change, and how it affects processes and people. One question that organizations need to ask themselves is if they are ready to embrace this change. And although the answer is usually positive, in reality you find that there is wide range of true readiness in each organization, and buy-in from the different affected groups will determine how fast they can move.

Canada initially planned for the migration to ICD-10 to take 2 years. The nationwide change took about 5 years to be complete. I would compare the ICD-10 migration to climbing a mountain. The time it will take you to climb it will depend on your strategy, your planning, your team, your equipment and your expertise, plus some variables that you can't control, such as the climate (please read vendor and payer readiness).

How many project management resources does a hospital need for an ICD-10 conversion?

Each organization is different, and its size and situation will determine the number of resources needed. The one thing that is clear is that there is a need for a dedicated project director who can oversee the entire conversion, not just the assessment phase, and supporting project management resources assisting in the various aspects of the project.

Before we close, you and I have joked before about some funny ICD-10 codes.  Do you have a favorite one, if only because it's downright goofy?

W59.22XD - Struck by turtle, subsequent encounter

What are the odds of being struck by a turtle, not bitten, and of the encounter to happen more than once?

Posted by Jack Williams at 12:19

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