Federally-Mandated Medical Coding Gums Up IT Ops

Lucas123 writes "The change over from a medical coding system in use since the 1970s to an updated version that adds more than 50,000 new 7-character codes is being compared to Y2K as an IT project that is nearly impossible to complete on time. ICD-10, which replaces ICD-9, adds far more granularity to medical diagnosis and treatment. For example, ICD-9 has one code for a finger amputation. In contrast, ICD-10 has a code for every finger and every section of every finger. An 'unfunded mandate,' the change over to ICD-10 codes is a multi-year project for hospitals, state Medicaid organizations, and insurance providers. The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records."

Comments

Structured data makes this easier

[Mjec]

Surely if the specification lists the data in a structured way, they don't need to be hard-coded. Can't you just stick them all in a database and do lookups? Can't the authority give that the requisite structure?

Re:Structured data makes this easier

[Registered Coward v2]

Surely if the specification lists the data in a structured way, they don't need to be hard-coded. Can't you just stick them all in a database and do lookups? Can't the authority give that the requisite structure?

I'm not so sure of that - one of the big problems would be how do you integrate 9 and 10 digit data so historical records are accurate as well as what happens when systems expecting 9 digits now see 10? There's a huge set of 9 digit data that won't simply go away and systems need to be redone to account for two separate data types. Data entry also needs to still account for 9 digit codes as service delivery and data entry dates could be far apart.

I guess you could simply add a digit to the 9 digit codes to make them 10 digit but I bet that would result in code overlap as well - or simply make all the 9 digit data no longer recognizable by systems.

Re:Structured data makes this easier

[crashumbc]

You don't work in the medical field do you? ICD codes are built into a lot of medical applications. For a famous slash dot car analogy, this is like trying to convert a U.S. car manufacturing plant over to use all metric.

Re:Structured data makes this easier

[wisty]

How about code that interfaces the db? If existing code is hard-coded, how would you change that?

Re:Structured data makes this easier

[MichaelSmith]

The article is actually pretty comprehensive and gives specific examples. I can easily see how this can turn into a nightmare. Everything in the hospital has to understand the new language. It has to be in the administrators excel spreadsheets, and the laptops used by the ambulance drivers, and the x-ray equipment. All the interfaces need to be validated because fuckups cost lives.

Re:Structured data makes this easier

[tbannist]

So it's something sensible that should have been done a long time ago?

Re:Structured data makes this easier

[Anonymous Coward]

They already use metric.

Re:Structured data makes this easier

[cpu6502]

I don't see any "sense" in adding codes merely to tell the doctor which finger was amputated. All he has to do is LOOK and see for himself which finger is missing. This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

It's also what bankrupted the treasury and led to the downfall of the Roman Empire (according to one historical theory).

Re:Structured data makes this easier

[Richard_at_work]

So thats it, its embedded in the core of the system so it is to never change again for the rest of mankinds existence?

Uhm, no - you eat the cost of changing over from poor prior decisions and design a system that is resilient to change this time.

Re:Structured data makes this easier

[Anonymous Coward]

Surely if the specification lists the data in a structured way, they don't need to be hard-coded. Can't you just stick them all in a database and do lookups? Can't the authority give that the requisite structure?

I work at a place where we are facing this. It isn't just one system. It is multiple legacy systems, some from vendors, some home-brewed, that are messaging each other back and forth. So sure, you're right, we'll get a time machine and go back in time and force all the builders of all of our legacy systems to code them perfectly so that it is just a single reference table lookup. No problem! I think every child should get their own pony too, while we're at it.

Re:Structured data makes this easier

[Anonymous Coward]

I don't see any "sense" in adding codes merely to tell the doctor which finger was amputated. All he has to do is LOOK and see for himself which finger is missing. This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

It's also what bankrupted the treasury and led to the downfall of the Roman Empire (according to one historical theory).

No but it *might* make sense to tell the surgeon which finger should be amputated so he/she removes the correct one...

Re:Structured data makes this easier

[Anonymous Coward]

Link is goatse.

Re:Structured data makes this easier

[tbannist]

Also the insurance company that has to compensate the guy who lost the finger(s) might like to know which one(s) were amputated and how much was amuptated. They pay different amounts for different fingers and different amounts depending on how many joints were lost.

Re:Structured data makes this easier

[Anonymous Coward]

I don't see any "sense" in adding codes merely to tell the doctor which finger was amputated. All he has to do is LOOK and see for himself which finger is missing. This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

It's also what bankrupted the treasury and led to the downfall of the Roman Empire (according to one historical theory).

I had a finger amputated. Tell me which one. Go on, just LOOK, after all, that's obvious, right?
Not like there's ever a situation where that information, individually or aggregated, might be useful to anyone in the spheres of research, information or analysis, without the patient in front of them, waving. And if it is, we can just line up all the amputees and they can look at them one at a time.
Alternatively, maybe it'd be handy to code this stuff up.
Just be grateful its ICD and not SNOMED CT, which contains over a million medical concepts.

Re:Structured data makes this easier

[Anonymous Coward]

They're versions, not digits. ICD-9 diagnosis codes (for some reason the International Classification of Diseases also has a set of procedure codes) use up to 5 digits in the form [0-9VE]##.##. ICD-10 is of the form X##.###X, except for some codes that have a "placeholder" to pad the middle of the code out to seven digits.

The real problem here is that insurance claim submission is real design-by-committee bullshit of the highest degree. It's an ANSI standard, a submember of ASC X12 so half the shit in there is unused crap needed for the other things X12 is used for, like wholesalers restocking their shelves or boats reporting their cargo, because apparently code reuse is so damn important to these people that the claim form has a section (completely unused for claims) for reporting credit card details. Of course, the insurance companies all took this design under advice and did their own shit with it. There's a code that identifies whether the insurance company is blue cross, medicare, medicaid and so on (that you have to put on the claim just in case blue cross forgot, and they apparently forget a lot, since if the clinic forgets to set this code properly, the insurance company uses every excuse possible to refuse to pay). Simple enough, right? Well when I started, we had an insurance company that used blue cross's servers for processing claims, so even though they weren't blue cross, this code had to be blue cross or BC's servers would shit themselves. Setting that aside, there's a completely separate code for what kind of provider ID you're sending (blue cross, medicare, medicaid and so on) because of course people are going to bill blue cross using medicaid IDs. Fortunately, the NPI did away with that bullshit (for the most part... medicaid here still demands provider IDs for checkups because they refuse to give up any hoops for doctors to jump through, and one of those was that the doctor had to use a different provider ID for checkups versus treating someone sick. Their computer system apparently cannot sort these claims out themselves... and yet if you bill a checkup on the wrong provider ID, the computer system can easily reject it. Hmmm...)

Ahem.... Anyways, instead of just adding a code to identify whether the diagnosis in question is using ICD-9 or ICD-10 (in the box the committee already created for the purpose of identifying the code being used), the committee got together and pretty much rewrote the whole damn thing. This is where IT got gummed up (it's getting better now). And believe me, you can talk about "legacy equipment" and other stuff til you're blue in the face, but claim submission is how doctors and hospitals get paid, that's where IT has been spending all of its time freaking out.

Re:Structured data makes this easier

[Anonymous Coward]

Do you have any notion of "eat the cost"? I work at a large medical institution (one of the monster sized ones) -- I saw a talk on the ICD-10 conversion by the group who's responsible for doing it -- I think they are underestimating it at 10's of M for our institution. I be it will end up costing multi-$B nationwide -- pick a number say $10B, we have maybe 250M insured, that's $40 per insured. Get out your wallet. I bet the $10B number is light and you'll end up with $200/person to support the coding change. As far "unfunded mandate" goes -- it'll get funded; funded from your paycheck.

Re:Structured data makes this easier

[mwvdlee]

The question isn't so much whether or not to design a system to be resilient to change, it's about exactly how resilient it should be.
In Y2K, many year fields were update from 2 to 4 digits. When the year 10,000 comes, we'll have to eat the cost of our poor design choices again.
Obviously, it completely unrealistic to expect any current software to run in the year 10,000. Just as it was completely realistic back in the 70's and 80's to expect any current software to run in the year 2000.
Perhaps a bit extreme of an example, but it's kinda hard to predict what might change in the future.
Besides, as explained elsewhere, it's not just a search&replace of codes; systems may have to be changed to accomodate both code systems at once.
For all we know, in a few decades a new religion will have taken over the world, introducing a new calendar and there we are stuck using our badly designed Gregorian calendar classes and routines.

Re:Structured data makes this easier

[codegen]

ICD-9 and ICD-10 are both 7 character codes. There are no lenth problems. The main problem is that about 15,000 codes have been dropped and about 65,000 codes have been added.

Re:Structured data makes this easier

[bill_mcgonigle]

how do you integrate 9 and 10 digit data

ICD-9 and ICD-10 are revisions of the standard, not field lengths.

ICD-9 is 3-5 characters in length, ICD-10 is 3-7 characters.

IIRC, ICD-9 will start with 'E' or 'V', else it's ICD-10.

Re:Structured data makes this easier

[thesh0ck]

Create Database, import v9 data with a new field in databsse called 'version' that has a 9 in it. Put all new data into database with 10 in the version field.

Re:Structured data makes this easier

[Anonymous Coward]

Ah, so you definitely don't work in the medical field, because you have no clue about this issue.
 
It's not "make work", it's a long overdue revision of the codes.
 
Here's an analogy; what if some doctor told you he thought the change to IPV6 was a "typical government 'make work' bureaucracy"? Your head would explode (we can only hope).

Re:Structured data makes this easier

[Anonymous Coward]

In fact that is what is done in most cases. I've actually written claim form processing systems, though I no longer do. In the US there are basically two standardized medical claim forms. On the forms next to the procedure code is a field for which coding system is being used. If it's an ICD-9 a "9" goes in that field to indicate you will be using an ICD-9 code. Presumably a "10" will go in that field when ICD-10 codes are being used. From there it's a simple lookup on the appropriate table.

The real impact here should not be at the IT level. A well built system should be easily adaptable to this scenario. In fact the system I worked on previously was built knowing that ICD-10 was on the horizon. The guy who replaced me when I left has already implemented it. It took him (one person) about a day. It's the office administrators and the insurance claim adjudicators that are going to feel the most impact. There are entire degrees in medical coding. People are going to have to learn the new coding system. Programmers, System Admins, DBAs - we don't care if the code that gets selected is correct. We only care that the person responsible for selecting the correct code has the tools to do so.

One other thing. This has nothing to do with diagnosis. It's all after the fact sort of stuff. Doctors will do what doctors do and won't really care about this other than as it impacts their bottom line because they had to pay to (re)train their office staff and buy an upgrade to their software. It won't stop accidents from happening. It will make it easier to identify problems after the fact. It will also make it easier for insurance companies to verify that the procedures performed were actually necessary - thereby making it easier for them to challenge a medical claim.

Re:Structured data makes this easier

[Anonymous Coward]

What if they're using the code to tell which finger NEEDS to be amputated? I'm sure you would rather your doctor specify which digit than to find out which one was selected after you wake up.

Re:Structured data makes this easier

[Anonymous Coward]

Programmers, System Admins, DBAs - we don't care if the code that gets selected is correct. We only care that the person responsible for selecting the correct code has the tools to do so.

I take that part back. The systems used by large hospitals and insurance companies automatically read the procedure codes and know what codes are generally appropriate together. For instance, you probably won't see heart transplant on the same claim as finger amputation. So there's going to be some coding around that. Smaller shops who aren't auto-adjudicating rely on their people to know what's appropriate.

Re:Structured data makes this easier

[betterunixthanunix]

It doesn't matter; if you were writing a system for dealing with these codes, the system should be flexible enough for the codes to change. What if there is some sort of revolutionary medical procedure that requires a new code? What if you want to sell the equipment to a country that has a different set of standards? There are plenty of reasons why someone might need to be able to change the codes.

Re:Structured data makes this easier

[Anonymous Coward]

LOL yeah because that never ended poorly

Re:Structured data makes this easier

[SatanicPuppy]

My thoughts exactly. It would only be a burden if you had to update the old records.

That being said, however, I'm sure that shit is hardcoded all over the damn place.

Re:Structured data makes this easier

[godefroi]

I actually do work in the "medical field", and more specifically, "medical informatics". ICD-10 has been coming for a LONG LONG time. It didn't take anyone by surprise.

Re:Structured data makes this easier

[Anonymous Coward]

The codes didn't simply change, the meaning behind the codes changed. Off the high horse now.

Re:Structured data makes this easier

[drinkypoo]

this is why we use XML and full-word data types. it doesn't matter then how many digits the year has as long as the hardware can accommodate.

nobody cares if we have a new calendar if we store time_t :D

Re:Structured data makes this easier

[VoidEngineer]

the system should be flexible enough for the codes to change.

Hehe... another person who doesn't work in the medical IT field, eh? If only. Ever heard of the Food and Drug Administration? They have this thing called 'FDA Approval' for software products. The change in format structure from ICD9 to ICD10 generally requires all the vendors of these systems to re-certify.

While these systems *should* be flexible enough to handle the code format changes, most of them aren't, due to federal certification and litigation reasons. The medical community would rather have a buggy system that's well documented and that they can create known work-arounds, than a flexible and adaptable system, with frequent updates, that could inadvertently introduce an undocumented error. In the medical field, '2 steps forward and 1 step back' doesn't cut it. So they require certification to prevent sliding back that one step, even if it prevents them moving forward 2 steps.

Re:Structured data makes this easier

[betterunixthanunix]

If the certification process prevents people from having configurable values for the medical codes, then the process is broken.

Re:Structured data makes this easier

[Anonymous Coward]

It's a bureaucratic thing to make sure nobody pays for the same finger twice.

Re:Structured data makes this easier

[brusk]

All he has to do is LOOK and see for himself which finger is missing.

What if more than one finger is missing, say one was lost in an accident and another had to be amputated? How would a doctor tell them apart without that being recorded? What about things like broken bones that have been set? It could be diagnostically important to know which bones have been broken and how they were fixed, but that's not visible from the outside.

Re:Structured data makes this easier

[VoidEngineer]

It's not just that a bunch of codes have been added or removed. The relationships between the codes have changed as well. What used to be a single code in ICD9 may have been replaced with a list of codes in ICD10 (or, worse, a tree structure of codes); and conversely, what used to be a dozen codes in ICD9 might have been replaced with a single code. The disjoint mapping of codes and their relationships is what's really gumming up the works.

Re:Structured data makes this easier

[tehcyder]

Also the insurance company that has to compensate the guy who lost the finger(s) might like to know which one(s) were amputated and how much was amuptated. They pay different amounts for different fingers and different amounts depending on how many joints were lost.

You get more for losing a thumb than a little finger, for instance.

Re:Structured data makes this easier

[idontgno]

Because, you know, changing configuration items never breaks software. It's just configuration! If it's important, hardcode it like a boss!

Sorry, you fail at basic configuration management, let alone certifiability for life-and-death purposes. You fix a configuration or a narrow range of configurations and certify that specific configuration. You don't let field weenies free-lance on your gamma knife or intravenous infusion pump.

The process is fine. Recertification is a valid cost, considering the safety implications of the alternatives. It's just unfortunate that this mandate is gonna force re-certification of practically every piece of healthcare IT all at once. Process bottleneck for sure.

Re:Structured data makes this easier

[tehcyder]

What if they're using the code to tell which finger NEEDS to be amputated? I'm sure you would rather your doctor specify which digit than to find out which one was selected after you wake up.

Well, they're bound to get the right one eventually, although it would be pretty bad luck to have to have ten operations...

Re:Structured data makes this easier

[VoidEngineer]

Yes, that's the easy and obvious part. Keeping both versions of the ICD9 code sets around is standard practice. The hard part involves the people and training issues related to phasing out legacy applications which are hard-coded to reference the old ICD9 codes.

Re:Structured data makes this easier

[mwvdlee]

You mean the time_t about to end in 2038? ;)

Also, time_t (even the 64-bit one) is a bit troublesome to use when storing DOB's before 1970.

And again; the problem isn't simply making a field bigger, it's about suddenly having to deal with two incompatible codes at the same time instead of one.

Re:Structured data makes this easier

[INT_QRK]

"CD-9 has one code for a finger amputation [. In contrast,] ICD-10 has a code for every finger and every section of every finger. Yikes! Perhaps the standards authors should have considered the principle tenet of the hypocrite oath: "First, do no harm!"

Re:Structured data makes this easier

[datapharmer]

simple, run date check, add a leading zero if before set date. If data is modified prompt for new code before saving. Not all old data will have enough information to be moved to the new system but this makes migration pretty simple. Only thing left is correlate old and new code categories which is probably tedious, but should be pretty straight forward.

Re:Structured data makes this easier

[drinkypoo]

You mean the time_t about to end in 2038? ;)

Also, time_t (even the 64-bit one) is a bit troublesome to use when storing DOB's before 1970.

so store a negative offset that looks like it :)

My desktop is 64 bit now... one of my notebooks could be but isn't, a laptop here could be but isn't... probably should be since it's running Linux.

Anyway it was a bit TIC but seriously, upgrade, upgrade, upgrade!

Re:Structured data makes this easier

[Anonymous Coward]

"I don't see any "sense" in adding codes merely to tell the doctor which finger was amputated."

It's more to tell the doctor WHICH finger to amputate. Something I think you would care a great deal more about if you were the amputee.

"This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs."

It probably doesn't make sense to you because you are ignorant of the facts. Maybe you shouldn't opine until you are, Hannity.

Re:Structured data makes this easier

[Anne_Nonymous]

Yes, but in Canada they have a health database that goes to 11.

Re:Structured data makes this easier

[Dr_Barnowl]

ICD is used to collate statistics, NOT to issue clinical orders, so this circumstance will not arise.

Re:Structured data makes this easier

[Anonymous Coward]

That information is recorded in their medical record.

Re:Structured data makes this easier

[geekoid]

Shut up, you have no idea what you are talking about.

Re:Structured data makes this easier

[Registered Coward v2]

simple, run date check, add a leading zero if before set date. If data is modified prompt for new code before saving. Not all old data will have enough information to be moved to the new system but this makes migration pretty simple. Only thing left is correlate old and new code categories which is probably tedious, but should be pretty straight forward.

While in theory data migration sounds easy; in practice it is far more complicated. I did a project for a financial migration where SSN's were used as employee ids (US company); so the IT types used that as the key to create the new records. After they did that they discovered so many duplicate records that manual analysis took forever. At first they did not believe my rule of 10's when it come to data migration - it will take 10x as long, cost 10x as much as in the plan and you will delete at least 10% of the data as unusable do to migration issues.

Re:Structured data makes this easier

[geekoid]

Assuming the doctor is there, and not looking at info on a computer, or that the insurance needs to know, other thousands of other reason people would be looking at record when the patient isn't there.

Like anyone who speaks outside their experience and expertise, you look like a complete and utter moron.

Re:Structured data makes this easier

[geekoid]

Correction:

Most of them aren't because they made the mistake of letting a lot of doctors drive the initial implementation. Same thing when you let accounts drive the design of finance data, or any other field.

Also, it is a reflection of very messy real world applications, and that can make it difficult for anyone.

And yes, they must have that level of certification to minimize risk. Otherwise people will die.

Re:Structured data makes this easier

[timeOday]

This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.

So your example of the typical government "make work" program is something that never happened?

It's absurd how medicine is practiced in the US today - two trillion dollars per year and most decisions made by the seat of the pants, with little or no cost/benefit analysis. We need to adopt Evidence-Based Medicine, and that requires information to determine the most cost-effective methods of care.

Re:Structured data makes this easier

[Anonymous Coward]

I deal with medical terminologies ICD-*, SNOMED CT, LOINC, and so on) every day. ICD-* are not used for clinical documentation - so ambulance drivers and X-ray machines won't see any ICD. They are used for coding diagnoses and procedures, and for billing and mortality and morbidity reporting. So, the billing and administration people will have a lot of headaches compared to the clinical users.

Re:Structured data makes this easier

[cpu6502]

>>>>> This is typical government "make work" bureaucracy that makes no more sense than going-round and busting windows to boost construction jobs.
>>
>>So your example of the typical government "make work" program is something that never happened?

Except it DID happen.
They destroyed cars in order
to boost construction jobs in factories.
It was called "Cash for Clunkers" and destroyed perfectly good and operational vehicles. Even the parts were destroyed, rather than recycled (very, very ungreen).

Re:Structured data makes this easier

[UncleTogie]

You get more for losing a thumb than a little finger, for instance.

I'm opposed to that idea...

Re:Structured data makes this easier

[VoidEngineer]

It really depends on that the process is for. As a change control system, meant to minimize the introduction of new and unknown quality control issues into the field, it's doing a pretty good job. Admittedly, as a system to get the latest bleeding-edge software configuration to market, it's pretty lousy.

That being said, the conversion from english to metric is a good analogy. In both systems, codes can be added and removed, without requiring certification. It's the hardcoded application stuff, related to the code formats, code versions, and code relationships, that require recertification.

Re:Structured data makes this easier

[VickiM]

IIRC, ICD-9 will start with 'E' or 'V', else it's ICD-10

Actually, I think E and V are different types of codes. Diseases, injuries and procedures are just numbers. E codes show injuries that were caused by external forces. I can't remember V off the top of my head; I think they're types of office visits.

Re:Structured data makes this easier

[Anonymous Coward]

It's always those legacy applications, isn't it? The question is how many business applications today are written to cause the same problem in the coming years. Mythical man month needs to be accompanied by the mythical legacy application.

Re:Structured data makes this easier

[Cyberax]

"hypocrite oath"

I thought that was the right to be free to change one's beliefs whenever it's convenient: http://www.penny-arcade.com/comic/2007/01/10/

Re:Structured data makes this easier

[INT_QRK]

Meant "hippocratic oath" but got strangely auto-spell-corrected...

Re:Structured data makes this easier

[Culture20]

2014- finger amputated due to irreparable physical damage.
2015- finger amputated due to zombie plague virus. Continue to monitor amputation site for signs of necropsy.
wouldn't it be nice to know which finger is which if the person is brought to the hospital unconscious?

Re:Structured data makes this easier

[s73v3r]

You say that, but having this level of granularity is actually a much needed benefit. How many stories have gone on about the wrong leg being amputated, or the wrong side of a patient's body being operated on. Not to mention, when the doctor is in his office, he's not going to run over to the patient's room, or call them up to ask which finger is missing. There simply isn't time.

This is not "make work" stuff, this is adding needed clarification to the system.

Re:Structured data makes this easier

[Anonymous Coward]

Great, now you've got me worrying about (no pun intended) fat-fingering the code for "amputate finger" into "amputate hand", but without the text which says "left index finger" able to raise a red flag about "woah, something doesn't match up here". :P

Re:Structured data makes this easier

[sessamoid]

You say that, but having this level of granularity is actually a much needed benefit. How many stories have gone on about the wrong leg being amputated, or the wrong side of a patient's body being operated on. Not to mention, when the doctor is in his office, he's not going to run over to the patient's room, or call them up to ask which finger is missing. There simply isn't time.

This is not "make work" stuff, this is adding needed clarification to the system.

This has nothing to do with eliminating medical errors. This coding is strictly for Medicare and Medicaid billing purposes. It's a shit-ton of extra work so the government can get even bigger.

Re:Structured data makes this easier

[tinkerghost]

Last report I saw said that between 30 and 50% of every medical dollar went to handling insurance.

Re:Structured data makes this easier

[Kalriath]

V is office visits according to our PMS.

Re:Structured data makes this easier

[HereIAmJH]

It's an ANSI standard, a submember of ASC X12 so half the shit in there is unused crap needed for the other things X12 is used for, like wholesalers restocking their shelves or boats reporting their cargo, because apparently code reuse is so damn important to these people that the claim form has a section (completely unused for claims) for reporting credit card details.

The problem with X12 isn't that is supports so many different industries, you don't need to support any transaction set you don't use, it's that it's too vague about how the data is represented within a transaction set. Once upon a time in another life, I used to create X12 211s (electronic bills of lading). And there were tiny, annoying differences with each carrier we interfaced with. It was simply because there wasn't a reference set that could be used as a final arbiter when there is a disagreement in the implementation. X12 would be so much easier to work with if there was a validator service like W3C.Org.

The real problem with insurance claims processing is that there is financial incentive to refuse payment for any reason. It's kind of like product rebates. The more submissions you can reject, the higher your profits. So muddy up the filing process and if a doctor forgets to dot an i or cross a t, then you just increased the executive's bonus. At some point it becomes cost effective for the doctor to write off a claim as a learning experience rather than try to collect from the insurance company.

Re:Structured data makes this easier

[HereIAmJH]

It was called "Cash for Clunkers" and destroyed perfectly good and operational vehicles. Even the parts were destroyed, rather than recycled (very, very ungreen).

Cash for Clunkers had goals beside increasing new car sales. In addition to boosting manufacturing, it was aimed at taking older, less fuel efficient and polluting cars off the road.

It's also inaccurate to say the parts couldn't be recycled. The engine block could not be sold as a working engine. (still had value as scrap metal) Many of the other parts were sold. The recyclers were less than pleased with the program though because they had a limited amount of time to remove the parts and crush the vehicles. They wanted to pay bargain prices to the dealers and then sell parts at a leisurely pace to get the highest price. Instead they had an over supply of parts and they couldn't sell them all short term. Which gave them the dilemma of whether to invest the labor in pulling parts to sell later, or crush sell-able parts. You'll notice that a lot more have warehouses of pre-pulled parts now. Ironically, it forced them to computerize their inventories and provide better customer service.

Re:Structured data makes this easier

[HereIAmJH]

This has nothing to do with eliminating medical errors. This coding is strictly for Medicare and Medicaid billing purposes. It's a shit-ton of extra work so the government can get even bigger.

Or a simpler explanation would be that they're trying to eliminate fraud from multiple billing for the same process. If a claim for amputation of a specified finger has already been paid, then reject any new claims for that finger. In the less specific older system you couldn't catch that until digit #11.

Re:Structured data makes this easier

[Anonymous Coward]

Do they not use metric? (genuinely interested to know)

If not, do all their overseas suppliers have to stock parts in legacy sizes?

International Standard

[rednip]

Medicare, like any insurer may change it's paperwork in an effort to make the process more accountable. As it's an international standard that has already progressed to ICD-10-CM, it's probably about time.

I bet you anything

[Rosco P. Coltrane]

the people who dreamt up the new coding system didn't even try to make it backward-compatible with the old one, hence the headaches and waste of money.

If ICD-10 was a superset of ICD-9, in a way similar to how UTF-8 is a superset of ASCII, the transition would be perfectly seamless and painless...

Re:I bet you anything

[Registered Coward v2]

the people who dreamt up the new coding system didn't even try to make it backward-compatible with the old one, hence the opportunity for systems houses and consultants to make a lot of money.

There, fixed that for you.

Re:I bet you anything

[jhoegl]

True.
As an IT guy who worked for a medical billing company I got to see the inner workings of the coding world.
It is interesting to see that it requires another human being to code from a doctors notes. And then many things came into play, such as alife medical, a EMR system that codes based off of what it reads. They even converted TIFFs with OCR so they could read it. Now with things like NextGen you can put it all into the system and let the system do it for you. No more "interpreting" what the doctor wanted to say. However, with this system it will be tough to find doctors who overbill or put in information that is untrue.
I would watch coders detect these things by finding a doctor attempting to charge for a procedure that did not even involve the issue. Can an EMR system do that? Hopefully, but it will probably be an after thought to the new coding.
And what about these certified coders? Do they have to retrain and re-certify? Probably.

That job was an eye opening experience into the Medical billing world. It was very interesting and I helped develop some of the very first medical billing methods.

Re:I bet you anything

[the_humeister]

Kind of like the IPv6 transition, eh?

Re:I bet you anything

[VoidEngineer]

Unfortunately, the old ICD9 is considered broken, so it's not suitable for supersetting. As an example, say that the skull is considered part of the head in ICD9, but the skull is considered part of the skeleton in ICD10. The code for skull has moved from 'head' to 'skeleton'. How do you superset that kind of relationship change? Worse, what if the original ICD9 relationship is considered no longer scientifically valid? What if a disease of an organ is reclassified to be a disease of blood? Or of the nervous system? Supersetting wouldn't fix those broken relationships.

Re:I bet you anything

[geekoid]

Except it's not possible. I suggest looking into why it isn't.

Re:I bet you anything

[geekoid]

". However, with this system it will be tough to find doctors who overbill or put in information that is untrue."

no it won't, in fact it will be easier.

Re:I bet you anything

[geekoid]

It's almost always impossible to super set when you are doing a refinements of a dataset of that reflects real world messy 'objects'

Most people don't understand that. Sadly, A lot of 'software people' don't get it either.

Re:I bet you anything

[frank_adrian314159]

If ICD-10 was a superset of ICD-9, ... the transition would be perfectly seamless and painless...On the other hand, if it were a superset, the people would simply continue to use the old ICD-9 codes which often specified treatments far too broadly and, in many cases, continue to be improperly reimbursed (read "reimbursed too much") due to this imprecision, and the transition to more granular codes would never happen.

Yes, it's a pain for the hospitals involved. However, this is something that was needed to do to help contain medical costs. And, since the health care suppliers had a financial incentive to not do this, it's something that would not have happened unless someone (like the government) mandated it.

Maybe this time the hospitals and EMR vendors will implement their system so that when a transition to (I guess) ICD-11 comes up, they can do it less painfully. Maybe they'll even clean up the medical vocabulary issues so that it's easier to translate codes. God knows that the HL-7 vocabulary committee has been around long enough to help with this.

Re:I bet you anything

[Anonymous Coward]

Or you just do like they did 3M stuff in the military: add another column to the look-up table. You'd be surprised how many different ways it's possible to look up stuff. Some of the depreciated numbering systems they have date for parts and equipage back to WWII.

Good.

[crow_t_robot]

The new system sounds much better and appears to be more accurate.

An 'unfunded mandate,' the change over to ICD-10 codes is a multi-year project for hospitals, state Medicaid organizations, and insurance providers. The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records."

This is good as well. Insurance company profits are ridiculous and hopefully this will force them to invest a lot of those profits in the American economy to do this work. Complaining about expense when replacing systems in a organization that is fraught with malpractice (misdiagnosis, amputating the wrong limb, dispensing the wrong medication) is ridiculous. This is akin to the government complaining about the cost of replacing infrastructure when the alternative is your car plunging in the river on your morning commute.

Re:Good.

[jhoegl]

Actually Insurance companies wont be involved in re-engineering the medical coding.
They just get the bill.

Re:Good.

[Anonymous Coward]

The misattribution of the reason for rising costs in health care is unfortunate. The fact that government as a payor is in this system is one of the main reasons costs rise as such a rate.

I work on the revenue side at a fairly large health system, and due to our population we have approximately 50% of our patients privately insured, and close to 50% are government insured. (There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe). The privately insured generally repay approximately what's billed, but for the government paid accounts, we would do well to recover 50%, 40% is a better guess. This is because the government solves its own budgetary problems by withholding increases to its medical payouts. In this area, we're still being paid at 2002 rates in 2011. We never withhold a needed service, so we just eat the cost.

But we have to make the books balance somehow. We're non-profit, but we still have to keep the lights on. Charge rates have to go up across the board, and the money lost on literally every government paid patient who walks in the door is then made up by the privately insured. You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else.

I think we're going to continue to have a huge gap of misunderstanding while people continue to emote over "big business" and "fat cats" and "obscene profits" without understanding what the real financial issues are on the ground.

Posted as AC due to PHB concerns.

Re:Good.

[gtall]

The insurance companies will only use this as a reason to raise rates. I presume in the long run it will make the system more efficient, but I do not believe it will make it cheaper simply because the insurance companies will eat any efficiencies and fail to pass them on to the consumer or the taxpayer.

If insurance companies were good for the health system, it would be fixed by now. They aren't and they need to be kneecapped.

Re:Good.

[JDevers]

As a quick note, misdiagnosis and malpractice are very rarely related. The other two things you list are gross misconduct. The wrong amputation is pretty rare but a devastating event. The wrong medication is much more common, but is rapidly becoming LESS common at least in hospitals with multiple error checks in the system to prevent it. Many modern medication administration records software systems force the administrator to verify identify via barcode scanners etc and then verify the drug using the same method. Orders entered into the system are verified by multiple sets of eyes. It DOES still happen, but isn't nearly as common in most settings. The ER and places like nursing homes are more likely. Even then the most likely situation is a pharmacist incorrectly filling a prescription to be taken home. It can range from life threatening to unnoticed in its effects. Misdiagnosis is very common and related to the difficulty in not only correctly diagnosing ailments but also actually getting correct descriptions of symptoms from patients. Most people do a piss poor job of describing what is wrong with them and many different diseases cause similar symptoms. These two things combine and most doctors start with the most likely explanation first and play a game of elimination from there. Humans are not computers, we can't give exact error codes that can then be immediately identified.

Gross misdiagnosis is another story and is related to incompetence and could be considered malpractice, but it also isn't that common.

Re:Good.

[jimbolauski]

This is good as well. Insurance company profits are ridiculous and hopefully this will force them to invest a lot of those profits in the American economy to do this work. Complaining about expense when replacing systems in a organization that is fraught with malpractice (misdiagnosis, amputating the wrong limb, dispensing the wrong medication) is ridiculous. This is akin to the government complaining about the cost of replacing infrastructure when the alternative is your car plunging in the river on your morning commute.

Insurance companies are not the villains making an obscene 5% profit, they will probably increase profit once this system is in place as they only have to change a few programs, over billing and other risks will be mitigated due to better identification of injuries. Hospitals and other health care providers are the one's who will feel the pain as they have to update all their systems many of which hard coded the values in and so every program has to be updated and tested to the medical standards (which is why the values were hard coded in the first place).

Re:Good.

[CrimsonAvenger]

Insurance company profits are ridiculous

Insurance company profits are less than 4%.

Which means that the only reason to invest in their stock is that they're not likely to tank anytime soon. It's not because of the huge profits they make.

Re:Good.

[iluvcapra]

This is a misconception. The United States has the ighest share of private spending per individual on health care, yet it has the highest costs and only middling health outcomes.

Every system in the developed world has a private spending component, usually through insurance and copays just like here, but most also have a government payer either as the single payer or more commonly as a backstop, last resort payer; all systems more firmly regulate costs and practices and all systems at least have independent boards to assure efficacy of treatments (we call those "death panels.") There's no empirical evidence that people make rational decisions about their own health care spending.

Re:Good.

[Entrope]

Insurance companies (or their subcontractors) will invest exactly enough money to make their systems find any inconsistency or miscoding in the insurance claim and reject the entire claim on that basis. They will not help hospitals or other care providers update their systems.

For example, my mother works in a small town pharmacy. One insurance claim was rejected by an insurance auditor because the date that the patient picked up the prescription was written on the back of a form rather than the front. It took the pharmacy owner many hours over many days to fix that "billing error" to the satisfaction of the insurance company's claims auditor, including convincing the patient to come back in to sign an updated claim -- after all, the date was added to the front of the sheet, and that change required the patient's signature to confirm that it was accurate. (Yes, it cost more in labor to fight the rejection than to give up on the claim, but my mother says the pharmacy's owner is rather head-strong.)

Re:Good.

[Anonymous Coward]

So, health care prices are high because the government will only pay $3.20 for a tylenol? Seriously? Are you sure greed doesn't come into somewhere?

Re:Good.

[valkraider]

Actually Insurance companies wont be involved in re-engineering the medical coding. They just get the bill.

Not true. The insurance company I worked for had a 3 year project to implement ICD-10 and it went relatively smoothly, and was not any more difficult than any of our other IT projects. It's just a project like any other project. Planned, budgeted, executed. Nothing to see here.

What TFA and other commentors don't seem to get is that the health industry is *massively regulated* and beurocratic. They have to deal with things like this *all the time*.

Between Medicare/Medicaid requirements, HIPAA, Health organizations (like Blue-Cross), HMO requirements, Drug laws, and every damn state having different Insurance commissions and regulations - EVERY YEAR insurance companies and hospitals and providers have to make massive system changes for one reason or another.

The pain in the ass is that most every law change always takes effect January 1. Which makes IT in the health industry suck between November and February. I wish they would some times pick different quarters to implement things in so that we could spread out the workload a little better.

Re:Good.

[SleazyRidr]

I see it like the mechanic who charges you $100 to tap your engine and make it work: it's only $1 for the tap, but it's $99 to know where to tap.

Re:Good.

[geekoid]

". The fact that government as a payor is in this system is one of the main reasons costs rise as such a rate."
no, it is not. In fact, it's cheaper.

Do you know why Canada gets cheap Meds? because the government is the payor? do you know why the VA gets meds cheaper then Canada? the government is the payor.

"(There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe)."
Wow, you don't see the fallacy there? really?

What nonsense.

"You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else."

No, it's because it is being administer by highly payed professionals.

Normal I don't respond to AC, but your post is so full of crap regards a hot topic issue, it needed to be pointed out you are full of crap.

Re:Good.

[geekoid]

Insurance companies make more the 5% profit, it's Pharma that makes around 5%

Also, that profit is after bonuses, and other expenses that don't exist in a government system.

Re:Good.

[snowgirl]

There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe

This is selection bias. We, who have no insurance, don't come into hospitals and other such stuff, because we're going to face enormous costs for doing so, because there is literally no one to pay for the costs, and it gets tacked onto our already shitty debt situation. So, we only head in to a doctor or hospital when we're afraid that whatever is wrong with us is going to kill us.

I had a clogged saliva gland in my mouth for like 3 months, guess what I did about it? Waited until it went away.

Re:Good.

[zraider]

Insurance company profits are ridiculous and hopefully this will force them to invest a lot of those profits in the American economy to do this work.

This is so moronic I don't know where to begin. How long have you worked in Healthcare IT? It's completely inaccurate to say that insurance companies are making ridiculous profits, and even if they were, who cares? Are you referring to any particular company? If so, which one? Are all types of health insurance companies making enormous profits, because I can tell you a lot of TPAs are losing business fast. Do you have any citations at all? All but the largest of insurance companies are struggling with compliance and investing in the American economy isn't the go-to solution. Try "investing in the Indian economy." Fixed that for you. I'm not making it up. It's not my personal theory. I work in the industry and see Americans lose their jobs every day due to cost pressures resulting from ill-conceived regulation. I don't disagree that the new code system will be beneficial, but the government took a disruptive approach in rolling it out.

they only have to change a few programs, over billing and other risks will be mitigated due to better identification of injuries.

Astoundingly inaccurate. The thing that people don't understand is that ICD-10 is not really an IT problem but an administration problem. Insurance companies must entirely redesign their benefit plans around the new code systems AND maintain payment neutrality at the same time, AND support dual code sets. Their adjudication platform vendors will be charging them massive amounts to upgrade and convert, not to mention their own resources. And when things go to hell, IT will be blamed because managers assumed that a one-to-one crosswalk was all that needed to be implemented. The cost of the conversion will be enormous for EVERYONE, and I predict the compliance deadline will be extended as a result.

Re:Good.

[Anonymous Coward]

If what you say is true, then the answer is medicare for all.

I don't agree with your assertions, but let's see what they are. You say that half your patients are Medicare and they pay you half of what you wish you were paid. So you are getting 75% the revenue you wish you were getting. But you have negotiating power over private insurance patients, who you can screw for charges well over their insurance company's "reasonable and customary" rates. This makes up some of the missing revenue.

The fact that you are in a position to screw over half your patients is what enables the Medicare system to be broken in the way that it is. If 100% of your patients were Medicare, then you would either (a) be forced to operate more efficiently, or (b) be forced to reduce your service level. But as long as you have option (c), gouge private insurance patients harder and deeper, you will take it.

Now, if Medicare for all were the law of the land, and you really (which I doubt very much) are operating at maximum efficiency, then services would start disappearing ... and people would start complaining and making it a voting issue ... and reimbursement rates would be grudgingly raised so you could maintain services. It is only the fact that you have another revenue source which makes this not happen.

And last but not least ... I am billing for my services at 2002 rates in 2011. A lot of people are making less in 2011 than 2002. There is no other sector of the economy where "2002 rates in 2011" is all that bad. The expectation that insurance and Medicare reimbursement rates will keep going up indefinitely is just plain wrong. The only question is whether the provider system or the insurance system breaks down first.

Re:Good.

[Anonymous Coward]

Sir, you must not work in health care. I do as an paramedic and biller.

". The fact that government as a payor is in this system is one of the main reasons costs rise as such a rate."
no, it is not. In fact, it's cheaper.

The fact that government is a payor is ONE REASON costs are rising as those who are supported by government (medicaid/medicare) are costing X dollars which is paid by the government at X*40%. Thus forcing everyone else to make up the difference. Another reason is the overall cost of supplying medical care to everyone 24/7/365. I don't make a lot of money as an EMT, but I have to pay my bills too. Everyone associated with a patient has their hand out for payment, including me as I went to the patients house at 4am in a $250,000 ambulance and administered $500 worth of medications and skills. My boss needs money to keep the lights on too. And the hospital needs to pay doctors a quarter million for their skills, and nurses to care for patients. All this costs money - there is no free lunch. Overhead is also a factor, as well as waste of resources, duplication of efforts, and fraud. Either way, there is a real cost for medical care. Government being a payor is ONE FACTOR.

Do you know why Canada gets cheap Meds? because the government is the payor? do you know why the VA gets meds cheaper then Canada? the government is the payor.

Canada gets cheaper drugs because that is what the market will bear. Canada government supplants medication costs to their citizens. I don't have actual figures to argue this point except to say that drugs costs whatever people will pay for them and I'm pretty sure pharmaceutical companies don't lose money in Canada. VA hospitals get cheaper drugs again because that is what the government will pay - but that real cost is shared amongst everyone else who can pay more. "Tax the rich" is what is going on here. Except the "rich" are those who have commercial insurance.

"(There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe)."
Wow, you don't see the fallacy there? really?

Sir, I work on the front lines of health care in both a metropolitan city and rural area. Very few of my patients have NO insurance at all. If I could guess, I would say 10% or less of the bills I have seen sent out are charged directly to the patient due to lack of any insurance whatsoever. This is true in my experience. This may not be true everywhere, but in my experience, more than 50% of our bills are to government supplied insurance.

"You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else."

No, it's because it is being administer by highly payed professionals.

This is again only part of the story. Not everyone who sees a patient is making $50/hr. I'm not. Our nurses are not. The cleaning staff is not. The desk secretary is not. The patient is not paying for anything in most cases - regardless of the insurance, although I know for a fact that medicare/medicaid pt pay nothing out of pocket. So yes some of the $8 tylenol goes to "highly paid professionals", but maybe only $2 of that fee. The rest goes to cover the costs of everyone else who doesn't pay anything. And medicare/medicaid recovers about $1 of that $8. This is my personal experience.

Unless you are actively involved with patients and billing, I would say you are just not that informed, which is fine, not everyone knows what happens behind the curtain. I however work directly with patients and with billing and what I have posted here is my informed, experienced opinion based on fact that I witness every day.

Re:Good.

[jhoegl]

interesting, because where I worked, we just billed them. They never got the EMR document unless requested.
But yes, there were changes every year. I remember seeing very large reference books being purchased on a yearly basis for the coders.

Oh and I love how government systems are still on dial up for submitting claims. True, it is pretty secure in the sense that it is a point to point connection into a terminal based system, but come on....
We handled this by implementing PGP encryption and SFTP and/or VPN Tunnels with hospitals.

Re:Good.

[Anonymous Coward]

Actually, what the AC says jibes with my own experience.

I work in a large hospital chain. For every dollar we spend on a Medicare patient, we are reimbursed 60-70 cents. We have to make up the difference somewhere, so we charge HMO plans essentially cost of care, and private insurance substantially above cost of care. About 50% of our patients are government paid.

For me, as a physician, Medicare pays me 50% of what I would normally charge. Medicaid is even worse. If a self-pay patient doesn't pay me, I can't claim it as a loss on my taxes. Though I work for the government 50% of the time, I cannot belong to a physician union to negotiate my wages, like a teacher or other public employee can.

Almost every country, regardless of how medical care is paid for, is experiences health cost inflation above the CPI.

If government funded health care is such a great deal, why doesn't Kaiser Permanente accept straight Medicare? (They do accept the Medicare Advantage plans, I believe, because they reimburse better.) Why is the Mayo Clinic no longer accepting Medicare? The simple answer: in our health care environment, one can't even break even with Medicare reimbursements.

(Posted as AC b/c I'm at work.)

Re:Good.

[iluvcapra]

For every dollar we spend on a Medicare patient, we are reimbursed 60-70 cents.We have to make up the difference somewhere, so we charge HMO plans essentially cost of care, and private insurance substantially above cost of care.

What difference? Does the reimbursement level not meet costs, or are you saying you need to bill more in order to make the projected revenue?

Though I work for the government 50% of the time, I cannot belong to a physician union to negotiate my wages, like a teacher or other public employee can.

Alas, you do have the AMA, which is not an industrial labor union in the complete Taft-Hartley sense but exhibits most of the functions of what is known as a guild. A guild is another form of labor syndicate, it does not strike, but instead it restricts labor supply in order to exert control over management -- guilds historically have used this power to control working conditions, and wages would rise secondarily as a function of the labor scarcity in the face of demand. Maybe doctors can't get COLA wage increases but I'd like to know what the "doc fix" is exactly if it's not a form of roundabout negotiated rate increase.

Almost every country, regardless of how medical care is paid for, is experiences health cost inflation above the CPI.

That's true, but the links back to the KFF show that our rate of increase still far exceed all other countries; it isn't strange for health care to take up more of its share of the economy given demographic issues and the fact that medicine is getting more effective.

If government funded health care is such a great deal, why doesn't Kaiser Permanente accept straight Medicare?

I don't think the Kaiser Family Foundation and Kaiser Permanente have any sort of organizational relationship aside from the money. Note I never said we should have government-funded health care, but it's clear laissez-faire policies in health care don't work and individual market discipline won't bring down prices -- it would just lead to a second renaissance of patent medicine and goat-gland surgery. You can have a mostly private-expenditure system if the rules work. (That a physician practicing wouldn't like this I can understand, you and your folks are the principle rentiers in the system, and definitely have the most to lose. Doctors in the German and UK health care systems are notoriously disgruntled. But doctors in Japan and Australia, a single-payer with secondary insurers system and private-insurers with community rating, do OK.)

Re:Good.

[Lehk228]

it would be better to go with a nationalized healthcare system where doctors work for the government and do not need to bill their procedures at all, and they would not need malpractice insurance at all, as long term injuries caused by errors would be dealt with through the existing public benefits system and medical costs incurred due to errors would be moot since medical costs would not fall upon the patient in the first place.

Re:Good.

[Anonymous Coward]

Most of what you say makes sense, until you get to the following:

Now, if Medicare for all were the law of the land, and you really (which I doubt very much) are operating at maximum efficiency, then services would start disappearing ... and people would start complaining and making it a voting issue ... and reimbursement rates would be grudgingly raised so you could maintain services.

That is not how America works. In America, people complaining (a) often don't vote, and, even if they were so inclined, (b) can easily be dissuaded from changing things by a few platitudes issued via television spots or astroturf campaigns. In America, rates of government payouts are contingent on the power of special interest groups, like health insurance companies, to purchase Congessmen. This is how America works, and this is also why there will never be Medicare for all.

You might have slightly more luck appealing to morality by declaring insurance to be a form of gambling: the bettors (the insured) wager that they will not get sick, and the bookies (the insurance companies) stay in business by making sure that they always charge more than they think the bettors are likely to "win" back (by falling ill or, more likely, by living to an age prolonged by constant medical attention). If the bettors look likely to win, insurance gets cancelled or some exception is found or invented—the game is rigged. The bookie makes money because he's always a step ahead of the bettor, always charging more than he's likely to have to pay out: another way to look at this is to see insurance companies as middlemen leeching off the financial transactions between doctor and client and off the fears of those not yet involved in such transactions. The latter part is the real kicker: they make the most money off the healthiest bettors (to return to the gambling metaphor), which means insurance is a bad bet for healthy, young people, but a strong demand for the old and infirm. Free-market ideologues like to say that the market handled this up until now by creating more competitive, lower-cost betting pools for the young and healthy (and by casting out the sick, who are more likely to win the bet), but they're easily refuted by a survey of health care insurance plan costs: there are no cheap ones, especially if you're under forty, white, and male: more than sixty percent of that group report not even seeing a doctor in the past year, and of the remaining forty percent, very few end up with expensive treatments. Statistically, they're far better off without insurance; their only motivation to place the bet is irrational fear that is statistically improbable. That leaves the bookies two options: (a) fear mongering ("imagine what might happen"), to lure in more bets from the healthy (to subsidize the sick), or (b) kick out the sick and the old from the betting pool after all their years of paying in. There's no happy, moral way for the bookies to improve the market or their own positions. At least a single-payer system removes the element of chance along with the middlemen: it becomes a social system rather than a gamble.

Re:Good.

[iluvcapra]

it would be better to go with a nationalized healthcare system where doctors work for the government and do not need to bill their procedures at all

Hopefully they will get paid according to some scheme where they get more for doing more, better, and more specialized work. Oh wait, we already do that now.

and they would not need malpractice insurance at all, as long term injuries caused by errors would be dealt with through the existing public benefits system and medical costs incurred due to errors would be moot since medical costs would not fall upon the patient in the first place

Hmmmmm.... no. Still need punitive damages and compensation for lost income and quality of life.

Re:Good.

[jwhitener]

(There are very few people coming in the doors who truly have no coverage, despite what the politicians would have you believe)

I worked at a hospital as a system analyst for 5 years and our non-profit was driven out of business by people using the ER as their healthcare plan without insurance. Different towns are going to have different patient populations. Politicians aren't lying about the number of uninsured in the country.

But we have to make the books balance somehow. ...You hear about $8 tylenol being billed, well, tylenol has to cost $8 because you're actually buying a whole bottle and sharing it with everyone else.

Private insurance isn't going to pay any amount the hospital asks. You could attempt to balance your books by raising the cost of Tylenol to 1 million dollars, but private insurance wouldn't pay for it. Just like the Government plans, private insurance has pricing guidelines. It isn't the Government insurance holders that are eating your profits, it is the actual cost of the equipment, nurses, doctors, pills, etc...

The hospital isn't buying heart stents for 1 dollar and charging 1,000 dollars for them to offset Medicaid patients. They are doing that because the Doctor is being paid 400,000 dollars a year, the nurse 90,000, the stent cost 800 dollars, the equipment in the operating room cost 1,000,000 dollars, etc...

Single-payer systems, like in France, drive the costs down in several ways. 1) That 400k doctor in the US would be making 150k in France, the nurse 60k. 2) Single payer = single buyer. Buying heart stents for the entire country lowers the price because of bulk 3) likewise with equipment purchases, 4) standardization across the entire country makes things tons more efficient. Oh, and they have better outcomes, except for cutting edge expensive stuff like rare cancers or odd diseases.

Re:Good.

[Anonymous Coward]

A lot of my non-profit's receipts from insurance companies go to cover the high portion of high use low re-imbursed goverment patients. If you want to end welfare or lower healthcare costs send your granny off to Siberia. Almost everyone over 65 is on medicare, and a lot of those folks get sick, and require a lot of care. The goverment doesn't pay enough to have someone with a bachelor's wiping her ass all night. When you come in to the ER with a headache and get billed $8 for a tylenol, that's where that $8 goes. The highly paid professionals have their own billing, that works much the same way.
There may be a large number of folks without coverage, but when you look at "charity care" outside of an inner-city hospital, the dollar precentage is lower than the population precentage.

Re:Good.

[Anonymous Coward]

The issue is not "government as payor" but rather "the US government as payor." There are other countries that get it right.

Re:Good.

[judoguy]

There's no empirical evidence that people make rational decisions about their own health care spending.

There's no empirical evidence that people make rational decisions about their own health care spending when a third party pays for it.

There, fixed it for you.

"Meaningful use" too

[Anonymous Coward]

TFA makes no mention of meaningful use, which is really taxing things... while it was marketed as being a way for health systems to earn monetary incentives by upgrading to EMRs, in reality what's going to happen everywhere, to every health system in the coming years is that one size fits all criteria is being foisted upon them in the form of very costly IT projects.

While there is a monetary payment from the government for the first few years for being in compliance, the cost to obtain financial reward X is significantly greater than X, but you have to do it anyway because non-compliance will result in heavy fines eventually.

And all these expenses are being piled on in economic times when health systems are already being crushed financially due to the state of the economy (lower patient volumes in general), terrible medicare/medicaid payouts, and the weight of supporting the government-insured, under insured, and uninsured (in that order) in general.

I know it's no surprise that national-level HIT management by the federal government has turned out to be not so grate akshully, but it is worth pointing out that Meaningful Use in the health care reform legislation is much worse than ICD-10

Re:"Meaningful use" too

[Machtyn]

It's amazing to me that while people see the actual damage of the government bureaucracy and decision making, they still believe that the government is the best entity to control major industries. (The statement is a generalization, there are also many people who do realize the waste and want smaller government, less to no entitlements, etc.)

Re:"Meaningful use" too

[brusk]

You do realize that in the US, government-run healthcare and government-run insurance plans spend far less on administrative costs that private insurers?

Re:"Meaningful use" too

[Lucas123]

FTA: "The move from ICD-9 to ICD-10, which changes out about 15,000 codes for approximately 68,000 new ones, comes at a time when care providers are already under the gun to implement and prove to the federal government the meaningful use of electronic health records (EHRs)." Try reading the actual article next time.

My last project involved ICD 9-10 Transition

[Anonymous Coward]

In my last project i was involved in making a tool called HPower10 which will allow organizations to effectively migrate from ICD 9 - 10. Similarly i was also a part of a HIPAA 4010-5010 migration tool. You can find more details here: http://www.hexaware.com/icd-transition.htm

Big $$$

[Subratik]

I'd love to be apart of that product manager's commission :( so what if it's going to take 5-10 years...

Re:Big $$$

[Subratik]

**Christine Armstrong, a principal at Deloitte Consulting, said in a report that ICD-10's complex code and its impact on EHRs, various billing systems, reporting packages and other decision-making and analytical systems will prompt major upgrades or the replacement of current systems. The changeover will probably cost larger hospitals between $2 million and $5 million, and large care groups as much as $20 million, said James Swanson, director of client services at Virtusa, an IT services and consulting company. ** Did you even get what I was saying? Anybody affiliated with leading ANY of those IT projects is bound to make over 300,000$ a year. Maybe you've become what you most hated, noob.

Re:Big $$$

[Subratik]

To elaborate, did you actually think someone was going to replace and upgrade this stuff for free? No, they just 'diverted' resources... Just because it's unfunded doesn't mean the people who are in the head aren't going to make it out with fat pockets. IE. Leaders of Non-Profit Organizations :) ---"It is pretty costly. A lot of other capital programs and initiatives are being deferred so these hospitals can work on the ICD-10 switchover," he said. "It crosses over so many different information systems. It's very broad in its scope." --- Oh yeah, you mean like the consulting pm's who are gonna bend over backwards for this headache aren't gonna get paid the usual sum of over 500$ per hour?

Re:Big $$$

[KUHurdler]

Did anyone else find it funny that we're talking about 9 vs 10 digits in the same summary as finger amputations?

Re:Big $$$

[Anonymous Coward]

Shut up idiot. I was just trolling and you actually replied. LOLZ!!!!onehunderedeleven!!!
 
Woosh!!!
 
hahahaha. LOL!!

Re:Big $$$

[OakDragon]

Yes I do! My immediate thought was... can the codes have fewer digits with succeeding amputations?

Makes a lot of sense

[swbozo]

It may be an "unfunded mandate", but it will probably help eliminate thousands of medical errors (mistaken amputations, incorrect medicine given to patients, etc.)

Re:Makes a lot of sense

[Registered Coward v2]

It may be an "unfunded mandate", but it will probably help eliminate thousands of medical errors (mistaken amputations, incorrect medicine given to patients, etc.)

Not really - the mistakes are made prior to the coding. Now you can just be more accurate about what was mistakenly done so you get paid for it.

Re:Makes a lot of sense

[Anonymous Coward]

No. Not at all.

Coding, is just a manner of recording in a concise format, what diagnosis was made, and what treatment was given. This way the data can be used for billing and statistics.

I have never, ever seen medical codes (be them ICD9, ICD10, SNOMED) ever used by doctors, medical technologists, or anyone with any direct influence over patient care. They aren't used in X-ray equipment (so there's no risk of incorrect examinations or incorrect interpretation), blood-work analysis machines, etc.

Being an MD, and part-time software developer, I've done a lot of work with medical databases. I looked at coding of educational files, and being able to import selected educational cases directly out of the hospital's electronic record system, in anonymised fasion, into an educational system. The first thing I noticed was that the coding (in this case ICD9) was extremely inaccurate, and often wildly misleading - fewer than half the codes I looked at were correct. The reason was that the coding was done by clerical staff, who read through the charts, and worked out what codes to use. These clerical staff weren't doctors, nurses, or other people trained in medical diagnosis. As a result, they would frequently misinterpret the charts and the wrong codes would be sent to billing and for government health statistics.

Re:Makes a lot of sense

[swbozo]

I'm not referring to misdiagnosis, but rather situations where the medical staff (pre-op and post-op nurses), for example mark the wrong limb for amputation. Having the code would make it possible for systematic checks to occur (say, a bar code not matching the medical procedure listed in the patient's file.)

Re:Makes a lot of sense

[Anonymous Coward]

Coding is used after the fact, not before. It's for record-keeping and billing.

  MDs rarely have any ICD-9 codes avail when going into surgery. When filling out the post-op paperwork, they are added.

Re:Makes a lot of sense

[Anonymous Coward]

There are already bar codes, double and triple checks by various personnel, and in some cases the patient actually marks with a sharpie which knee it is they will have surgery on, for example. Everywhere in the case the "laterality" (can't recall what the technical word is) is spelled out. It's really amazing that any of those errors occur. This was always rare but exponentially less so 30 years ago, today it is exceedingly, exceedingly rare.

In any case, providers don't use coding, coding is done after the time of service for billing/records purposes.

Re:Makes a lot of sense

[Registered Coward v2]

There are already bar codes, double and triple checks by various personnel, and in some cases the patient actually marks with a sharpie which knee it is they will have surgery on, for example. Everywhere in the case the "laterality" (can't recall what the technical word is) is spelled out. It's really amazing that any of those errors occur. This was always rare but exponentially less so 30 years ago, today it is exceedingly, exceedingly rare.

Actually, it's probably more amazing that more don't occur. I've done post event investigations numerous times; and left/right top/bottom mixups are not that unusual. The clinicians I've worked with recommend the Sharpie method, as well as making every person who comes in contact with you properly clean their hands in your presence.

Re:Makes a lot of sense

[AngryNick]

Having the code would make it possible for systematic checks to occur (say, a bar code not matching the medical procedure listed in the patient's file.)

Huge taxonomies always seem to make a lot of sense to the people who make the reports or design the "systematic checks" you mention. In real life, however, the workers are pressed for time and will take the path of least resistance. If that means selecting the first instance of "finger" that appears on the list, then so be it. One can hope medical professionals wouldn't be that way, but I suspect some aren't as respectful of your database values as your reports might require. The almost universal reliance on Sharpies is a great example of a user interface problem being corrected by users instead of programmers.

Re:Makes a lot of sense

[geekoid]

"Being an MD, and part-time software developer,"

Dear lord, stop. I worked with a lot of MDs who said that to me. Stop doing it. Stick to proper medical care.

Do you know why IDC9 is such a mess? because it had a bunch of "Being an MD, and part-time software developer," involved in its creation.

I know I know, you know what you are doing, those other MDs and part time Software developers don't.

Re:Makes a lot of sense

[Anonymous Coward]

You're right about ICD9 and ICD10, but there are several clinical documentation systems that use SNOMED CT, and other clinical terminologies. Some of the advanced EMR systems (Kaiser Permanente and a few other leading medical informatics centers) use SNOMED CT for their problem list manager and an error here can directly impact patient safety. However, I agree that ICD9 or ICD10 coding errors do not directly affect patient safety unless someone uses them for problem lists or diagnosis in the medical record, which they shouldn't be doing in the first place. (MD with a PhD in medical informatics here).

Re:Makes a lot of sense

[snowgirl]

I've seen doctors use coding. The last place I had healthcare at had to assign every prescription or test to a coding of what it was intended to treat/diagnose.

Re:Makes a lot of sense

[dmr001]

I don't know what setting you work in (or where - I'm in the United States), but in outpatient settings (where most of physicians are, I think) every MD/DO/MA I know uses ICD-9 codes all day long. They are used for eligibility, insurance, lab ordering, referrals and if they aren't exactly right it leads to a world of hurt (patients get improperly billed, sick people can't get tests done or see specialists), , and clerical staff expect us to do the actual coding; they do the processing.

Re:Makes a lot of sense

[sessamoid]

"Being an MD, and part-time software developer,"

Dear lord, stop. I worked with a lot of MDs who said that to me. Stop doing it. Stick to proper medical care.

Do you know why IDC9 is such a mess? because it had a bunch of "Being an MD, and part-time software developer," involved in its creation.

I know I know, you know what you are doing, those other MDs and part time Software developers don't.

Well, somebody has to design the software that we use, and most of the nightmares in EMR have to do with the people making the program not having a clue as to how it's actually used. There are those of us who are both physicians and have enough coding experience that can make that situation better. But according to you, we should just let laypeople design medical software. Sure, that makes perfect sense.

Re:Makes a lot of sense

[Doctor Faustus]

The professor I had for database systems and bioinformatics worked for the computer science department, but was an MD -- he seemed to be pretty good.

Re:Makes a lot of sense

[Sad Loser]

IAAMD, also national data representative for medical college.

this is absolutely right
big taxonomies are are designed by people who don't use them. There is a degree of prick measuring - 'my taxonomy is bigger than yours'
Silly to go to ICD10 when that's already out of date and SNOMED is available.

In the long term, complete EPR with native SNOMED coding is the way to go, but in the meantime give me a small taxonomy with minimal inter-coder variation.

Re:Makes a lot of sense

[Kalriath]

You must be insane. SNOMED has a whopping 390,022 codes in it, in an ungodly tree structure. At least with ICD-10 it's only 23,321 codes and it's pretty much flat.

Re:Makes a lot of sense

[Anonymous Coward]

I've seen coding apps directed at MD for various hand helds starting with the palm3. Google ICD iphone and see a plethora of results.

Re:Makes a lot of sense

[gmhowell]

I think the OP means he hasn't seen it used to describe (in clinical terms) a condition or treatment, he hasn't seen them used to issue orders, etc.

Hard?

[Anonymous Coward]

How hard could this be? Isn't there a conversion table so you can (using the finger example) - mark all legacy data as the first finger, first joint - with a migrated data flag so you know it's probably not digit accurate?

Do they seriously have to review each record to get it right for old data? If so - that is unreasonable.

Re:Hard?

[TimeOut42]

So, you are recommending putting bad data into the database as a better option? GIGO....

HOLD ON A SECOND HERE !!

[Anonymous Coward]

Are you telling me this is going to happen ?? Think of the children !! Why am I not surprised /. is supporting this ?? It's true. /. are co

HOLD ON !!

Scratch that. I was reading the text on the stall;s wall here.

meh.

[Ephemeriis]

The effort, which affects dozens of core systems, is taxing IT operational budgets at a time when shops are already under the gun to implement electronic health records.

For the most part, this isn't my problem.

ICD-10 has been on the radar for a while now. At least a couple years. And it's Federally mandated. So we didn't have any problem adding the necessary funds to our budget this year.

Each of our HIS vendors has already got ICD-10 stuff ready to go. We'll have to pay them for their time, or a software release, or whatever... But, as far as my own labor is concerned, it'll basically involve giving them remote access or throwing a disc in the drive.

Most of the labor involved is in our coding department. They're going to have to send folks out to get (re)trained in the ICD-10 stuff. They are, understandably, a little stressed. But they've been working on this for a while, too.

Re:meh.

[Anonymous Coward]

Must be nice to work at a small facility where you use COTS software. :) Larger places don't have that luxury since many COTS packages don't scale well.

Re:meh.

[frank_adrian314159]

ICD-10 has been on the radar for a while now. At least a couple years.

It was on the radar when I was working on health care information systems eight years ago. All of the EMR/billing vendors had it supported back then. The only reason that hospitals haven't implemented it by now is obstinacy. Bitching about it at this late date is like listening to a smoker crying about his lung cancer.

It doesn't exactly sound like a waste of time

[Anonymous Coward]

At the risk of sounding like I'm sending in a Whaaaaambulance, this seems like a worthy project. Seriously, is anyone suggesting that we should still be stuck in the 70s with healthcare diagnostics? It would be a frigging laugh if someone suggested that since it's too difficult for IT to do, healthcare diagnostics should not try to catch up to where it should be.

And really? The Feds needed to mandate this to get it done? With all the noise about how private healthcare really has out backs and we don't really need government healthcare, this seems like a pretty good example of exactly why we DO need government healthcare.

No sympathy for the whiners.

Re:It doesn't exactly sound like a waste of time

[crashumbc]

FYI, this really doesn't affect the diagnostics. 98%+ of it has to do with billing. Just because there was only one code for amputating a finger doesn't have anything to with the doctor doing his job. He does cuts it off describes what was done in the chart(or EMR) then after the person is discharged a person in a little room called a "coder" goes through the chart and enters the billing code(ICD-9 currently) in the bill that gets sent off to the insurance company.

Re:It doesn't exactly sound like a waste of time

[Qzukk]

The Feds needed to mandate this to get it done?

Stuff like this is like infrastructure, the private companies will wait until it is completely disintegrating then try to get someone else to pay for it instead of spending money that could better be used for bonuses on capital improvement projects. ICD-10 was finished in 1992. So we're not stuck in the 70s, we're stuck in the 90s.

It doesn't help that all the private insurance companies have hitched their trailer to Medicare and do "whatever Medicare does", whether it's with regards to pay (doctors tell me that almost all private insurers pay a set percentage of whatever Medicare pays, which is why they're scream so loud every time Medicare cuts come up) or whatnot. At this point it doesn't take a law for the feds to "mandate" anything, if Medicare does it, monkey see monkey do.

And it slows things down

[m0s3m8n]

As the spouse of a Physician (hospitablist) and a System Admin for a medical practice, I can tell you first hand that is a cluster f&*%. The effect this crap is to slow down physicians with tasks that they really should not be doing, (read data entry). That is exactly what these regulations are doing. And to keep productivity up, some doctors are resorting to hiring scribes who follow them around, just increasing costs that will get absorbed somewhere. It all looks good on paper but the effect is reducing productivity of the people on the front lines.

Re:And it slows things down

[BlackHawk]

As someone who's working with this stuff right now, I can say if it's slowing you down, you're not taking advantage of the available tools. They're out there. Keep looking. Moreover, "data entry" is one way of looking at it. A different way to call it is "documenting what they're doing with sufficient detail". That was the entire point of these kinds of standardized coding systems: to (as best as we can) remove the fuzzy documentation in the systems before, and to remove the idiosyncrasies from medical records. With the proper coding systems in place, a patient in Allentown who moves to Duluth can have his PHI moved to the new caregiver and be (for the most part) confident that the Iowans will be able to understand what the Pennsylvanians did for him before. Yeah, there's going to be transitional pain. There always is. But as has been pointed out in other posts, it's not like ICD-10 ambushed anybody. Frankly, if you haven't been moving toward ICD-10-capable systems for at least 2 years, you've been slacking. There's a penalty for that at crunch time.

Re:And it slows things down

[Anonymous Coward]

ICD-10 has been in the pipeline for many years. One of the advantages of ICD-10 is the greater degree of specificity that a procedure is coded at. This helps the medical facility get reimbursed at the highest possible rate for procedures preformed, as well as gives the patient's EHR more accurate information. There will need to be some changes to encounter forms ( a sheet that practices use that have the most used codes in the practice listed). The layout between ICD-9 and ICD-10 is very similar.

Re:And it slows things down

[geekoid]

Your problems is in the input method and tracking.

Also, OF COURSE THE DR SHOULD DO THIS. They just don't want to and like to bitch and moan.

It's a small trade off in overall time. Yeah, slower up fronts, but more accuracy and speed down the line.
If they don't have the time, then they are understaffed and should deal with it appropriately.

You know what? there was a time where doctors where too busy to wash there hands.

Re:And it slows things down

[geekoid]

He is just repeating what Drs bitch about' Too busy, too busy. What they mean is 'It's beneath me.'

Re:And it slows things down

[Anonymous Coward]

The ICD codes are not used for communication of medical information except as it pertains to billing. The subtleties of medical diagnoses and treatments cannot be summarized with the crude tool of ICD coding in a manner relevant for clinical decision making. ICD codes are there to make the life of administrators and accountants easier.

If a patient was to move from Pennsylvania to Minnesota and all that was included was that "Mrs Smith has a diagnosis of 174.4 with 198.5 and a new 198.3 and is moving back to Duluth to be closer to family" this would be next to worthless for medical decision making no matter how many digits you add to the codes.

Re:And it slows things down

[BoberFett]

Oh, so you would rather have a doctor billing at hundreds of dollars an hour worry about doing data entry instead of a $20/hr coder?

Let me guess, you also like to whine about the rising cost of healthcare?

Re:And it slows things down

[Anonymous Coward]

I'm a doctor, and I can tell you that clinicians never use ICD-9 codes, and won't be using ICD-10 codes. These are applied after the fact, primarily for billing and regulatory purposes. Plus, the wrong codes get entered extremely frequently, because the people who use ICD-9 have no understanding of the medical conditions described by the codes.

This increased granularity might be useful if the data were actually accurate, but that is unlikely to be the case. It certainly wasn't the case with ICD-9, and I doubt it will be any better with a system that is ten times as large and unwieldy. It's pure "garbage in, garbage out".

Nearly Impossible?

[vlm]

being compared to Y2K as an IT project that is nearly impossible to complete on time.

That sounds like good copy to a lowly journalist, but as someone "who was there" during Y2K, what was "nearly impossible"? We knew it was coming, we planned, the bosses mostly used it as an excuse to semi-fraudulently ram upgrades thru and as a powerful weapon to grab more budget money. It was way, big time, trivial.

Besides, just think about it. The entire world's IT department, all those guys who can't close open relays, blah blah blah all somehow 100% successfully did the nearly impossible... yeah uh huh.

Re:Nearly Impossible?

[BlackHawk]

Amen to this. I got hired on by a company on Madison, WI in January of 1999 and was told on my first day that "this Y2K thing" was my first priority, since my predecessor had put in maybe 3 hours of work on the project. Oh, and I had to do it while getting our network up to date. Frankly, it was a cinch, once they'd approved the budget. *That* took until June, too, so I really did the entire project in 6 months.

Re:Nearly Impossible?

[Anonymous Coward]

Is Epic still using that godawful char-pointer-based database system as a backend instead of an RDBMS?

Procrastination hurts

[RKThoadan]

While this is definitely a huge pain, I have little sympathy for those complaining about the timing of this when the standard was finalized in 1992.

Re:Procrastination hurts

[Tony Isaac]

Actually, the final rule was published January 16, 2009. http://journal.ahima.org/2009/02/05/analyzing-the-icd-10-final-rule/

Many major EMR software systems, such as Centricity, are still not ready for ICD10, so there is nothing for providers to upgrade to yet.

It's not just about procrastination, it's also about government ineptitude and impossible mandates.

Cry me a river

[Enry]

ICD-10 has been out for nearly 20 years. There was a 5 year timeline to get ICD-10 implemented, and there was likely a few years of discussion with major Medi* billers before that to let them know this was coming along.

Much like the FCC and HDTV, health care companies must have ignored the mandates until it was too late, whined and cried about how they couldn't meet such a strict deadline and pretty please can we extend it for another 5 years. Repeat until our health care records system is completely unusable.

Though, wow, I would have thought VistA would have ICD-10, but it's being bolted on now. Strange.

Re:Cry me a river

[crow_t_robot]

It appears to me that most hospitals/medi orgs were dragging their feet to see how it would play out:

"Quite frankly, the hold up is it's a big undertaking and it took them a while to get under way. Everybody's started, but a large percentage of hospitals are in the heavy analysis stage or they're just starting," said Casey Corcoran, vice president commercial solutions for healthcare at General Dynamics Information Technology, a vendor offering ICD-10 consulting services.

"heavy analysis": heavy procrastination

Re:Cry me a river

[Gideon Wells]

More and more I keep hearing "unfunded mandate" or "harsh deadline", but experience is translating it as "I waited till the last minute and now I'm screwed."

Re:Cry me a river

[Anonymous Coward]

To be fair, WHO based ICD-10 has been out for 20 years. ICD-10-CM (the American verison) is fairly new and is something like 4x the size of WHO's set.

Re:Cry me a river

[Anonymous Coward]

You are right on with your comment -- the WHO approved ICD-10 years ago and the US is one of the last countries to implement. The implementation date in the US has been pushed back a number of times. Hopefully the government claims systems will be updated to accept the new ICD-10 codes on the same timeline.

Re:Cry me a river

[guruevi]

Do you have any idea how some medical centers operate? The small ones are usually nimble enough to change on a drop of a hat. It's the big ones that use many, many closed source, proprietary software for records and then hire loads of contractors to write more closed, proprietary middleware to link them all together that are going to have the problems. Most of these medical software companies go out of business after having sold their 'product' to about 2-5 large clients so finding somebody that understands the code, structure or just about anything of it is nearly impossible.

If open source should prosper anywhere, it would be in the specialized software business. However greed and fear have driven many of these project impossible to alter so they have to be re-implemented every couple of years. Most of the cases they are simply interfaces on a database with some simple validation.

Re:Cry me a river

[Machtyn]

Which sounds just like high school and probably a lot of a student's college experience.

Re:Cry me a river

[Anonymous Coward]

No kidding. Don't cry to me about government mandate when you have five years to implement it. You want to cry about five years? Let me tell you the pain of re-implementing 10% of your code in six months!

Re:Cry me a river

[Anonymous Coward]

Open source *is* prospering in healthcare. http://www.mirthcorp.com/community/mirth-connect - this is one of the most popular interface engines out there. You can download the free version and use it right now or you can pay the company for support/appliances/custom work.

Disclaimer - I was a heavy user of this software. I am now an employee of the company.

Re:Cry me a river

[Anonymous Coward]

While the standard has been out there a long time, there are a lot of standards that have been out there a long time. You care about them when you need or have to use them. ICD-10 was not used in the US (ICD-11 is under development now, by the way), and there was a long debate on whether to go to ICD-10 or SNOMED-CT. The government only decided this two years ago, so while the standard has been out there a while (among many) you wouldn't know what to implement until recently. The US has its own version of this "standard" as well, just to keep things interesting.

This is before you get into the issues of how much work this is (not just a systems issue, many healthcare professionals have codes memorized and we've had years of auditing to decide what is appropriate documentation for a code assignment - all needs replacing). And, a lot of the people who need to invest in the change do not receive a lot of benefit for this change. The insurance companies don't really need the change, their actuarial tables work just fine as an example.

So, ICD-10 is technically a better coding system. But it's not really going to improve a doctors day to day life, the interstate records sharing issues are actually a small percentage of use case, the trend analysis data will have a big crack in time, and its pushing physicians to be data entry clerks and removing them from the collection of data (if you believe in the data-information-knowledge-wisdom chain).

I'm not sure the FCC/HDTV analogy holds. The HDTV delays were because consumers had rejected the expensive television sets. I don't think consumers care which coding system is used for payment data between computer systems.

What is the ICD-10 code

[Chrisq]

What is the ICD-10 code for being a dickless idiot. They could save time by automatically adding it to the record of all Federal employees. OK - maybe not the FBI - honestly I didn't mean you, I was just sayi.....

Re:What is the ICD-10 code

[weeboo0104]

What is the ICD-10 code for being a dickless idiot. They could save time by automatically adding it to the record of all Federal employees. OK - maybe not the FBI - honestly I didn't mean you, I was just sayi.....

The ICD-10 codes for being a dickless idiot would be:
Q56.4 Indeterminate sex
F79.1 Unspecified mental retardation with significant impairment of behaviour requiring attention or treatment

Re:What is the ICD-10 code

[stubob]

N52.2, Drug-induced erectile dysfunction?

S38.01, Crushing injury of penis?

Re:What is the ICD-10 code

[nitehawk214]

What is the ICD-10 code for being a dickless idiot.

S38.2 Traumatic amputation of external genital organs
F73 Profound mental retardation

The fun part about ICD codes are you get 3 replies with 3 different codes for the same problem.

Re:What is the ICD-10 code

[Anonymous Coward]

S38.221A
S38.22 - Traumatic amputation of penis
S38.221 - Complete traumatic amputation of penis
S38.221A - initial encounter

http://www.icd10data.com/ICD10CM/Codes/S00-T88/S30-S39/S38-

Unless you mean a preexisting condition or something, which isn't a diagnosis.

Re:What is the ICD-10 code

[geekoid]

Here are some federal employees I would like to see you say that to there face:

http://www.marines.com/

Stop using crap languages and hardware

[exabrial]

If you really have a problem with extending a field by a few bytes, you're using the wrong language. By now, you should expect the world is going to change constantly. If it's a surprise to you at this point congress is going to re-invent healthcare ever two years to boost their ratings, please beat yourself with your keyboard.

Let me guess, the people complaining are using z/os hardware and wrote everything in cobol accessing a ADABAS database. Some idiot business manager said, "It ain't broke, lets not upgrade" and decided to continue using their billion dollar IBM dildo for the next 15 years.

Re:Stop using crap languages and hardware

[bill_mcgonigle]

When I left the hospital IT in the last decade, they were still writing everything in a niche language developed in-house by a power company in the next state. Nothing in the way of data integrity developed since the 60's with relational databases, and all of the productivity of a 40 year old language. This was the largest healthcare organization in the state.

Oh, they were going to upgrade to Visual Basic for some of the new code when I bolted for the door. Those who understood computer science were reviled for proposing technology the bosses couldn't themselves operate (monetary and patient-safety business cases were dismissed as irrelevant).

Last I heard from the grapevine they were going to trash the whole thing and fork-lift upgrade to a vendor's product. At least that vendor would have had to compete on his merits in the marketplace.

Oh, yeah, the point: don't try to apply normal IT thinking to healthcare, it's about politics, not IT.

Re:Stop using crap languages and hardware

[Anonymous Coward]

Some idiot business manager said, "It ain't broke, lets not upgrade" and decided to continue using their billion dollar IBM dildo for the next 15 years.

amen !

Re:Stop using crap languages and hardware

[exabrial]

I bet you worked for Cerner...

Re:Stop using crap languages and hardware

[stubob]

The problem isn't the extra bytes, the problem is that the codes now provide so much more description. So there needs to be translation between what the doctors are used to calling something and what the new term is.

For example, in ICD-9, one code is 944.15, First degree burn of palm. In ICD-10, there are three codes: Burn of first degree of unspecified palm, initial encounter, subsequent encounter, and sequella (subsequent encounters). ICD-10 also defines additional codes for Burn of first degree of left palm, right palm. So that makes 9 possible new codes for that one ICD-9 code. But whoever is entering the data needs to know that there is the additional accuracy in the new system.

Re:Stop using crap languages and hardware

[geekoid]

See, that attitude is the problem.
When I worked in healthcare, I used good software design. If a MD wanted to change things, or wanted me to do it differently, I just asked them if they would personally take the liability if it cause someone to die.

Yes I pissed off a lot of MDS. and they stayed pissed all the way up until the started using my software; At which point they get a lot friendly, and on TWO separate times I got an apology. Wish was quite shocking.

Bottom line: Know software, and explain exactly why something won't work. Never say 'People like it like this" or 'In my opinion it works better..." IF you are saying that then you might want to take a real good look in the mirror and ask your self if you really understand software, od if you jsut slap stuff together and call it good it it happens to work.

Here is a test:
Take a relatively complex software engineering concept (like bubble sort) and explain it to a 10 year old. If they get it after a few minute, you know what you are talking about. If not, then you have failed.

I literally do something like this from time to time to be sure I really understand something, and not just have 'feel' for what's correct.

Re:Stop using crap languages and hardware

[Anonymous Coward]

Two of the largest (in terms of number of hospitals using their product) health vendors in the US use a database written in MUMPS written in the late 60's.

Re:Stop using crap languages and hardware

[bill_mcgonigle]

Bottom line: Know software, and explain exactly why something won't work.

Yeah, I made up nice pictures, explained two-phase commit to the suits, why moving data between multiple databases without two-phase commit could be dangerous, calculated how many serious medication errors we might expect on a yearly basis (7, as I recall) and was told that it would be cheaper to settle the lawsuits than to do the software correctly. It wasn't a lack of understanding, it was a lack of caring.

I worked on my resume that night.

Funny....

[Anonymous Coward]

Not so hard as they say, ICD10 to ICD9, I did it before from pseudo ICD9 to real ICD9, just gimme a job. I think the real problem is within health professional workers. :)

Don't visit the link above, everyone.

[Anonymous Coward]

Don't visit the link above, everyone. -sigh- Especially at work.

Re:And it hurts too

[Anonymous Coward]

Asshole

Rest of the world already uses it for years

[Anonymous Coward]

I quite don't understand the whining here. Germany for example is using ICD-10 (first in a slightly modified version, now the standard one) since 2000, over ten years!

As always the USA are only very slow in adoption but other countries have shown that it can be done and that it does not warrant the whining we are seeing here.

So shut the fuck up and just do it already. And after that continue with adoption of metric units.

dear healthcare companies, providers, etc.:

[circletimessquare]

maybe we can use this to pinpoint where you assholes waste so much cash

is that why you whine about it?

Re:dear healthcare companies, providers, etc.:

[Anonymous Coward]

maybe we can use this to pinpoint where you assholes waste so much cash

is that why you whine about it?

More likely, this will be used to second guess doctors' clinical judgment in order to save a few bucks.

Re:dear healthcare companies, providers, etc.:

[circletimessquare]

yeah, save a few bucks: what the fuck do you think is wrong with that goal? do you know how financially wasteful our healthcare system is?

Re:dear healthcare companies, providers, etc.:

[silas_moeckel]

On the golf course?

Not directly but by buying whatever sales guy got chummy with the PHB and insists will fix everything. It generally cost more does less, is a giant pita to make work and follows no standards even there own.

Re:dear healthcare companies, providers, etc.:

[Anonymous Coward]

If you cancer care doesn't get paid for because of the whim of a beancounter it will be a big deal for you. It happens.

Re:dear healthcare companies, providers, etc.:

[circletimessquare]

care for cancer is not healthcare waste, einstein. you can't think of any SYSTEMIC wastes of cash?

Not that good of an analogy

[Anonymous Coward]

You don't work in the medical field do you? ICD codes are built into a lot of medical applications. For a famous slash dot car analogy, this is like trying to convert a U.S. car manufacturing plant over to use all metric.

The funny part is that US car makers are already converted over to metric.

I guess it wasn't that hard.

Re:Not that good of an analogy

[blueg3]

US cars use metric fasteners?

Re:Not that good of an analogy

[TheLink]

Yep, they use metric for every 2.54cm of the car.

Replacing 70s systems with 90s system

[entirely_fluffy]

ICD-10 is not exactly new: from http://en.wikipedia.org/wiki/ICD-10

.

"Work on ICD-10 began in 1983 and was completed in 1992"

Re:Replacing 70s systems with 90s system

[gregarican]

In addition there is over two years left to implement this in the U.S. according to what I see. *yawn* (from a person who helped with Y2K projects back in the day).

Re:And it hurts too...

[Anonymous Coward]

Giggles. That made my day. Thank you.

Total Bullshit

[Saerko]

As pretty much everyone else has already said, if you don't have a system that can quickly and easily update from ICD-9 to ICD-10, you're so far behind the IT implementation curve that you should be drug out into the street and shot.

It's 2011. They've had many, many years to upgrade, and now they're poised to paid by the government to do so. Hell, my employer stands to gain $50 million dollars over the next couple years from implementing key portions of the HITECH provisions in ARRA. For those reading, that's more than half of my (quite large and well-funded) health system's annual budget.

For our part, we just slapped down a couple hundred thousand for a product that hot-swaps our ICD-9 coding for ICD-10, and also tosses in a problem list that physicians can use that's tied to these coding schema, potentially improving efficiency and accuracy as well. The only excuse, and I mean ONLY excuse for ICD-10 being a problem is poor IT leadership within the health system/hospital--a failing which is incredibly, unbelievably common.

I'm lucky, I work in an IT shop that actually has its shit together.

Re:Total Bullshit

[Anonymous Coward]

Very well said! I was going to call BS, because anyone that can't do this is, as you said, very far behind the curve and doesn't have their shit together. To me, this looks like the sorrier IT groups are just using this as an excuse to thieve more money away from the rest of the organization (whose job is, presumably, to better people's lives, rather than give money to shitty CIOs and their minions).

I'm sick of the incompetence that pervades so much of the IT workforce.

Re:Total Bullshit

[Anonymous Coward]

You think that a health system with a budget under $100M is quite large? The budget for one of this year's projects my employer just finished was almost $50M. Our IT budget alone is several hundred million per year. We are TRULY a quite large health system (over $2Billion in revenues a year and typically several hundred million in profits). I guarantee that your shop would NOT be able to handle our work load. It seems, from your comments, that you are a small scale thinker. This is a large scale problem.

First, are you just now implementing problem lists? We have had them for years. And they have to be built to accommodate different specialties (we call them groupers), which numbers in the hundreds. Then there are the interfaces, external systems, diagnosis linked to meds and procedures, systems such as NEBO and other external billing systems, reporting. The list goes on.

While I agree that it was lack of foresight on the part of vendors and others that are causing this Y2K like panic, implementing ICD-10 in a health system with over 10K clinicians, 300K patient visits (that's outpatient, inpatient, ambulatory, ED, and the various types of surgical) per quarter, and multiple linked systems is not so easy as "slapping down a couple hundred thousand for a product that hot-swaps our ICD-9 coding for ICD-10".

We have been planning for this problem for the past few years and are just BARELY scratching the surface. And I also work for an IT shop that has its shit together.

Re:Total Bullshit

[Saerko]

We have been planning for this problem for the past few years and are just BARELY scratching the surface. And I also work for an IT shop that has its shit together.

Funny, our annual revenues and net profit are very close to yours, yet we support 1/10th the clinicians. Are you supporting multiple EHRs that are interfaced, or running something frankenstein-esque like McKesson? Because that might be the first problem. Our health system has one inpatient system, period, for all entities.

As to the problem list issue, it really came down to the political climate. Physicians have to be dragged kicking and screaming into the 21st century, and as an academic health system they end up in all of the leadership positions. It's only in the last 5 years that they decided they need to even have electronic documentation, and we've been racing to catch up to our peers. I'll level with you--we're about 3 years behind where we really should be for the level at which we're trying to play, but change management due to new regulation is not one of our issues.

Re:Total Bullshit

[Anonymous Coward]

No one is buying your business on slashdot, so no need to bullshit. I have heard several companies make such claims (it's easy, we have the conversion already done, trust us). All just bullshit trying to get more undeserved money. I find it hard to believe your company to so much better than everyone else.

Re:Total Bullshit

[Anonymous Coward]

Yeah, our's is pretty much the same way. I just gave the MR director a quote on a new server for the updated coding software.
Yes, your employer may reap $50 million but they'll probably spend $75 million. MU payouts were never meant to be a profit center for providers. The funds were meant to help the provider install and use an EHR.

Re:Total Bullshit

[Anonymous Coward]

As pretty much everyone else has already said, if you don't have a system that can quickly and easily update from ICD-9 to ICD-10, you're so far behind the IT implementation curve that you should be drug out into the street and shot.

It's 2011. They've had many, many years to upgrade, and now they're poised to paid by the government to do so. Hell, my employer stands to gain $50 million dollars over the next couple years from implementing key portions of the HITECH provisions in ARRA. For those reading, that's more than half of my (quite large and well-funded) health system's annual budget.

For our part, we just slapped down a couple hundred thousand for a product that hot-swaps our ICD-9 coding for ICD-10, and also tosses in a problem list that physicians can use that's tied to these coding schema, potentially improving efficiency and accuracy as well. The only excuse, and I mean ONLY excuse for ICD-10 being a problem is poor IT leadership within the health system/hospital--a failing which is incredibly, unbelievably common.

I'm lucky, I work in an IT shop that actually has its shit together.

whats ICD-10, I'm in I.T for a Hospital! Plus where do I get it? There are many Health Care systems.

So...

[MadKeithV]

What they are saying is that ICD-10 is implemented through ID-10-T managment?

Think positively

[Anonymous Coward]

I try to think of these kinds of things as "job security". Yes, they're a headache for all involved. Self-centered and a bit callous, I know, but then again those traits are the basis for modern capitalism.

I know what will fix this...

[Anonymous Coward]

...XML!

Re:And it hurts too...

[Anonymous Coward]

Do not click the link, it is goatse.

The good news . . .

[Mondak]

. . . is that you don't need to change historical data. There is a hard, day forward switchover date in October 2013. The lookup problem is that there is not a one to one relationship between the old codes and the new ones. The lookup would need to contain a level of intelligence that just simply isn't contained anywhere within the context of the data set. This means that every level needs to comply to get the data. You don't just need the space for the correct number of digits, or add logic to append a "19" or "20" in front of your year. - The doctor needs to be retrained (NOT an easy task since many already "know" everything they will ever need to know) to record the information from the encounter with the patient. - Then the coder needs to select the right codes (assuming the system they use can even handle the new codes). - The billing system needs to be capable of transmitting the new codes (new EDI x-12 rules go into effect in Jan 2012 to support this) - The payer's claim system need to be able to store the new codes - The contract between payer and provider on what amount will be paid for what service needs to be completely rewritten - The payer's examiners / adjudication process must be able to interpret the codes vs. the treatment codes to decide whether to pay the claim at all (Diagnosis = stubbed toe: treatment = removed kidney. . . no pay)

Re:And it hurts too...

[Anonymous Coward]

Motherfucker. Some of us are at work and don't want to have a drilled out anus pop up on their fucking screen. Christ.

Re:'unfunded mandate'

[Anonymous Coward]

What's changed is skyrocketing medical malpractice insurance brought about by money-grubbing malpractice lawyers, drug companies spending billions on advertising to the masses that increases drug costs, patients who come in demanding specific high-cost tests (MRI, etc), and insurance companies who are determined to pay as little as possible for medical care, forcing the hospitals to absorb or pass on a lot of costs, and the great uninsured masses who go to the emergency room to see someone about their cold. It's not government interference that's driven health care costs up; it's the corporations.

Typos

[Anonymous Coward]

"Federally-Mandated Medical Coding"? Why are you hyphenating with an adverb ending in -ly? What is with this trend? It's redundant. Either drop the hyphen or drop the -ly. Or "Federal Lee-Mandated" if someone in the federal government named Lee is doing the mandating.

And "The change over from..."? In this context, "changeover" is one compound word.

Re:And it hurts too...

[Anonymous Coward]

How many times are you going to spam this link? Like we don't know where that goes......

Job creation

[Anonymous Coward]

This is one of the ways that the government "creates" jobs. Now we just need for them to mandate telephone sanitizers.

Unfunded mandate?

[hellfire]

I thought the 2009 stimulus package had $30 Billion which was to be paid to hospitals to update their systems? The only backup I have for this is an I, Cringley article I read over the weekend but I'd feel he'd of all IT writers would be a reasonably reliable and impartial source. Definitely a far more reliable source than the average Slashdot submission.

Re:Unfunded mandate?

[geekoid]

yep. Also, they have had 10 years to develop an implementation process.

But instead that didn't take it seriously until the last minute, and then blame the government.

Re:Unfunded mandate?

[Chitlenz]

Hmm this isn't really true now is it? For the record, NOBODY knew what the actual final standard for US healthcare would be until Sept 2010 (although the preliminary final ruling was July 2010, but still...). While ICD9 to 10 may have taken ten years, there was no reason to believe it was going to float to the top of the coding systems expected for use until it was written into the federal register last year. And its not like there's a ton of options or anything that could have replaced it, making early adoption risky and potentially pointless or anything.

You want ICD-10

[Anonymous Coward]

ICD-10 IS a dramatic improvement over ICD-9, and you want hospitals to invest the time to implement it. Why?

  - The US is the only industrialized in the world that is not using it (this matters if you want your medical records to be accessible when you travel)

  - ICD-9 cannot accurately characterize diseases with enough granularity for use besides billing (this matters if you want electronic health care records that are accurate, enable things like clinical support systems, and better medical research)

  - With ICD-10 and more specific links between disease, we can better track the progression of disease through populations (this matters if you want get the bird flu and want proper treatment and response, which in ICD-9 is characterized as "pneumonia" because theres no code for it)

So I understand that theres a knee-jerk tendency to say "the man is foist all this on me!" But this time the men, and women, are making an improvement thats going to save lives and money in the long run.

Re:You want ICD-10

[random coward]

So I want the billing system to switch to ICD-10 so that the government and my insurance company know more about my health than they do now.

You're mustachioed and are watching out for me aren't you?

but this one goes to 11...

[Thud457]

We're waiting to leapfrog from ICD-9 to ICD-11. We're expecting to save a boatload of effort that way.

Re:'unfunded mandate'

[Anonymous Coward]

Really? That's the difference between a hospital room in the late 40's and now? The paperwork? Not the EKG's/IV's/TV's /etc that every patient is constantly hooked up to? Don't you think the latter could have added to the cost just a little bit?

Re:And it hurts too...

[dotsandot]

Thanks for the food.

Favorites:
"FUCK.YOU.ASS.HOLE."
"Ugh. Goatse. NSFW. Asshole (poster and picture, both)."
"Seriously ... new account to post that ... what a douche!"
"You're a fucking douchbag." - "That is the most accurate comment yet"
"I hope you die in a fire before you are old enough to contaminate the gene pool."
"Death to all assholes - Let's put you first into the guillotine"
"Asshole... Ginormous asshole, in fact."
"Ugh. Goatse. You asshole."
"Better than you, you arse bandit."
"My word, what is wrong with your anus? I'd get that checked out dotdotdotter."
"Motherfucker. Some of us are at work and don't want to have a drilled out anus pop up on their fucking screen. Christ."

Hate:
"I hate your guts."
"WTF you fucking asshole."
"You're a lowlife faggot piece of shit."
"Damn! Mod this fucker to hell"
"Fucking troll, do not click there"
"It would be more interesting if I had a piece of pipe and your face, in close proximity so I could smash your face beyond recognition,"
"You fucker" - "I had the same thought as you. What a fucking asshole. The link is nsfw."
"Bravo teeny bopper. You're a really mature mother fucker (or do you prefer father fucking? Damn you homo erotic shittter)."
"Wait! I think I hear your mommy calling to give your tongue a good soap washing. And maybe she'll execute you too"
"You fucking piece of shit!" , "You sorry piece of shit." , "You cunt.", "Fuck you."
"I did not even bother to look, but this same idiot has been doing this for weeks now. Fuck off asshole."
"What a retard..... enough said...."
"Asshole. literally. Goatse is so old. Grow up you fool."

Funny:
"Damnit! nearly 15 years reading /. and I still fall in a goatse.cx trap !"
"It's because of Assholes like you that I can no longer trust URL shorteners"
"Didn't click it, but the magic 8-ball says goatse."
"Would advise against clicking the link in the troll post above. Especially if you're at work atm."
"Thanks, I'm reading slashdot in class like a good student and just got tubgirl'd."
"Not gonna click it to find out, but I'd be surprised if parent's link wasn't goatse... It appears you would be correct sir. Why oh why do I always forget.."
"Watching second monitor, there was something wrong with the other screen. Control + w. Phew..."
"Doh! One has to also recognize data urls. *sigh*"
"That's somewhat clever, but some of us do know what base-64 encoding is."
"Can you not afford normal entertainment?"
"Hey family! Come look! They're opening the Google Talk client! Now, click here...... (sees goatse)"
"I tried to post warnings about the goaste loving jerk yesterday but was modded into oblivion as a karma whore"
"Turn on TinyUrl previews. It saves lives."
"Posting your picture online again?"
"Really? Are you not tired of this yet?"
"High likelyhood of being a Goatse link. Proceed with caution"
"This is grown up talk, 4chan is that way ->"
"Hey moron, try using different links."
(Me posts goatse link and tells it is SFW): "You mean NSFW asshole."
"Yup, this is what your life amounted to. Posting goatse on Slashdot and collecting comment trophies."

Emotion:
"i WAS eating lunch you ass!"
"Oh dear god my eyes. Haven't seen THAT awful image in a while."
"My eyes are burning... argh! Damn you!"
"MY EYES... dude i am at work here "S "
"WARNING: Don't click on the parent's link! Damn goatse! The first I experienced, no less.
"Oh goddammit. I didn't need that right before bed."
"goatse warning! I'm still recovering."
"Please friends, I beg of you, do not click that link! Do not look at that image, whatever you do! It is a bad image! It is a goatse image."
"*sigh* Goatse alert..."

Frustration:
"Can someone make a fucking goatse blocker firefox plugin please? This is pissing me off now."
"I am sick and tired of that crap on /. "

Philosophy:
"Goatse trolls are getting

Not so easy for EMR support

[Anonymous Coward]

I am a programmer for one of the largest hospitals in Chicago, and I can tell you from our perspective this is a nightmare.

For example, we have sets built for each area in the hospital to make it easier for clinicians to choose a diagnosis such as when they are updating the patients problem list (part of Meaningful Use) or ordering. Someone in Hem-Onc probably will never have the opportunity to enter a diagnosis for amputation so we remove that option for them. These sets will all need to be rebuilt. By hand.

In addition, for each procedure or medication there is a linked diagnosis for billing. All of these medications (we have over 100k in our system right now) and procedures (over 50k) will need to be re-linked to the new appropriate diagnosis. And it's not as easy as "All procedure X should be linked to diagnosis group Y", it's much more fine grained than that.

Then there are clinical concepts that will need to be linked, such as those released by IMO and SNOMED.

And the interfaces to external systems, be it radiology, billing, or external like NEBO will have to be modified to distinguish between ICD-9 (for historical data) and ICD-10 and send the appropriate HL7 messages.

And the reports that are based on ICD codes. Oh, the reports.

This whole thing is a real headache.

But I do agree that, since ICD-10 was finalized in 1993, and has been in use around the world since around then, EMR vendors should have seen this coming and at least built nice tools to make it easier.

Re:'unfunded mandate'

[Anonymous Coward]

Wrong. It's not government interference, that's a really stupid thing to say. Health care costs have risen mostly because of American consumers' demands to get the latest, most expensive treatments, whether they help or not, and also treating medical malpractice suits as a lotto ticket, which raises malpractice insurance, and forces doctors to provide much more expensive and unnecessary treatment, to avoid being sued into bankruptcy.
 
Government-run Medicare costs have gone up about half as quickly as costs for private insurers. Medicare SAVES money.
 
Take off your tinfoil hat, you troll.
 
Paperwork, by jeebus! Wow, just... wow.

No excuse

[Anonymous Coward]

What's the issue here? Some slow-to-evolve hospitals are complaining they can't keep up? Any system that has a decent EHR can implement ICD-10 with relative ease. Even the federal US Department of Veterans Affairs has been working on planning its implementation for years now, so, if the government can even do it - why can't all these "advanced" private sector places do it on time? Rubbish.

Oh please. That's just horse puckey.

[Anonymous Coward]

So what's changed since then?
- Government regulations that require TONS more paperwork (like ICD-10), additional labor just to do that paperwork, and thereby cause costs to skyrocket.

Pardon me for stepping in your Ayn Rand fantasy world, but that's not the important thing that's changed. Costs of government mandated paperwork are not a significant part of the problem of exploding costs. Deregulation of the insurance industry and over-regulation of drug sales and production have been much, much worse on the bottom line.

Speaking as a person working in the field of medical billing and collections for the last two decades, the problem is not government paperwork - in fact HIPAA was a huge benefit to both patients and providers once the pain and suffering of implementing it was done - the problem is mostly in the private sector - principally the insurance companies.

Government mandates that force individuals to use for-profit insurance companies are making things worse, yes, but fundamentally the insurance industry makes money by not paying claims for as long as possible. Every day they can delay paying for your emergency C-section generates profit for them. In practice, this is a Darwinian "invisible hand" acting on insurance providers that selects for inefficiency and poor customer service. The insurance company that is the slowest to pay, and pays the least, makes the most profit, and then buys out the faster, better paying providers. Thus an entire secondary industry has sprung up that does nothing but force insurance providers to pay up, generally by creating and tracking massive amounts of paperwork.

Government is not fixing the problems, but it's not creating them by mandating paperwork - it's perpetuating them by pandering to "all regulation is bad" ideologues who are preventing simple and effective health care regulation. Things will get worse if the government continues to permit the consolidation of private insurance companies. Things were vastly better before the insurance companies were allowed to buy each other out by the Reagan and Clinton administrations, who never met a monopolist they didn't like.

If the automobile and health industries were nationalized, we could solve these economic incentive misalignments, eliminate income tax, and still balance the budget. If individuals were free to decide for themselves what drugs they should be allowed to take, the costs of medical testing would drop through the floor. But nobody will back those simple measures, because the right wing won't stand for nationalizing of rich men's cash cows, and the left won't stand for letting people make their own mistakes.

Y U no code?

[Anonymous Coward]

Hmm, I have to code my charts all the time - but maybe that has to do with working at a University, and the patients are pretty varied.

MOD PARENT UP!

[sgtrock]

This is overlooked time and again.

So what?

[Anonymous Coward]

Our software has supported both longer than I can remember so I don't get what the point is. ("coding system" + "code") is just a surrogate key into a bigger table of codes. Does software actually exist that uses an ICD-9 code directly as a key? LOL. Amateurs. (Unfortunately, it seems a lot of medical software is actually written by medical people, who at the end of the day don't have a clue about software. Or DB design.)

Re:So what?

[PPH]

Does software actually exist that uses an ICD-9 code directly as a key? LOL. Amateurs.

I've seen worse. Not in the medical records biz but elsewhere. (Where exactly, I probably shouldn't say. Or you'll never get on an airplane again.) There's a good change that some apps have done something like hard-code ICD-9 codes (or ranges).

I've seen systems where a code was used to indicate some position on a shop floor, or process. And then management negotiated a union contract based upon code values or ranges. And now, when the s/w folks try to fix it, everyone up through the legal department and labor relations up through the company president comes unglued.

Increased costs - for profit insurance

[spineboy]

Hello,
  I am a surgeon, and I can tell you a lot of the cost is from all the middle men (ins companies), and defensive medicine. It's not the doctors who are making the big bucks. One of my patients said to me.
  "Yeah Doc, the bill was big, but your part of the bill was peanuts - I feel sorry for you."

Most MDs pay about 10% off the top of profits for a billing service because it's so complex.
Many additional x-rays, lab tests are also ordered because we worry about "missing" something, and being sued. There are articles published about MDs doing that - its a real phenomenon. That's probably another 10% as well.
Large malpractice insurance (average $30k to $200K per year!!)- guess who has to pay for that...
Insurance companies - they are a new middle man. A whole industry has popped up, and the patient care has to burden the cost. They also inundate doctors offices with paperwork (20 page disability forms)- making it a pain in the ass to collect money. Many groups hire Physician assisstants to fill out paperwork, because there is so much of it.

SO yeah - costs have gone up,

Re:'unfunded mandate'

[geekoid]

In every objective study, the government has kept costs down, overall.

What has changes since them is technology.

Now we have safer rooms, many gases delivers through an internal system, more equipment, higher trained professional, and a large population.

You anecdote is crap, an not normal anecdote crap, but emotional based ignorant anecdotal crap.

Also, in the 40's and 50s a lot more people died.

Today, he might not have even needed to stay on the hospital.

Seriously implying the health care was better back in the day is just stupid.

wait.. he was a 'poor farmer' but still managed to pay even though he couldn't work the farm? He was a poor farmer that could have afforded rent on top of his farm?

There is an old robot saying for this: "DOES NOT COMPUTE."

Re:Not so Good.

[Anonymous Coward]

I am not a medical doctor but in my opinion: Health insurance was supposed to spread the high cost of unlikely treatments among the people purchasing it. Since higher volume leads to higher profits for the insurance companies, health insurance morphed into paying for low cost, high-likelihood procedures as well. There is reinforcing feedback since more volume means higher profits at a fixed profit percentage. The side effect is that executive salaries skyrocket since they are managing more money. Also, since direct feedback to the insured person's wallet was removed, every insured person does not consider if the procedure is worth the cost at the time of service. They are "paying for" and "need to get their money's worth from" the insurance so they deserve the procedure whatever the cost and whatever the efficacy. Of course, this causes costs to spiral upwards. The insured get their medical benefits, the insurance executive get higher profits, the doctors get higher profits, and insurance costs keep going up. Executive then try to start excluding insured with expensive conditions from their insurance rolls, start charging different rates for different age brackets, and blocking people with lapses in coverage from getting insurance unless they have no preexisting conditions. In my opinion, health insurance percent coverage of treatment should be based upon what percentage of your life you have purchased health insurance coverage and not on whether you could get and pay for health insurance that month.

That's not the half of it...

[geminidomino]

The ICD-9/ICD-10 change over is a ballbuster, but is far from the worst of the lot. Useless "meaningful use" requirements based on closed standards that aren't complete or even accurate, at best, and contradictory at worst and the clusterfuck of the new ASC X12 formatting are both bigger pains in the ass, though I guess I'm lucky that the software I work on was at least clueful enough to store the codes in a database...

I'm on my 6th week of overtime now thanks to this BS.

Codes are for insurance not health

[Anonymous Coward]

- What is the ICD10 code for the middle finger, because that is the basic system we have for health care in this software industry.

- The ICD9, 10 codes are driven by insurance and payment systems. There would be a more health based system if there was single payer health care in the country. The VA had the biggest most robust electronic health record system, but it was tossed away like Microsoft throws away standards for profits.

- Lack of standard API and billing considerations make the competing software systems incompatible anyway, think early file transfer between MS and Apple and Unix and IBM mainframes. Think competing ERP systems and "seamless" integration of SAP and Oracle business systems. Not happening.

- The lack of user interface design and design errors in electronic health record software is killing people. And vendors do not get nailed for the deaths, blaming
the "users" for basic design problems.

Yeah, I did that stuff for a living, it was worse than when I made nuclear weapon launch systems. I am a bad person. But not as bad as the insurance company presidents. And I post AC for a reason.

Re:Codes are for insurance not health

[rgbatduke]

Amen, brother!

(I too did some of this, but not for a living, as a sideline. But you are dead on the money.)

rgb

Re:And it hurts too...

[geminidomino]

One of these days, this asshole's gonna have a hard drive crash and lose his precious list, consigning his life's work to oblivion. He'll probably kill himself.

It's sad, really...

[rgbatduke]

Having gone through an entire long term consulting gig assessing EMRs (electronic medical record packages) and installing and helping to run and EMR for a largish medical practice, I've seen firsthand a bit of the mess that is IT in medical practice. IDC-9 and IDC-10 are just the tip of a very big iceberg. It is already (for all practical purposes) impossible to run a medical practice even with IDC-9 without an EMR and practice management interface. These electronic tools are very expensive initially, a total pain to maintain (and an ongoing expense to maintain), and more often than not terribly designed and clunky for the physicians, nurses, lab, and office staff to use. IDC-10 is the icing on the cake -- with it it is absolutely impossible to try to continue to operate "by hand". The government is armtwisting medical practices towards the use of electronic medical records and practice management in various other ways -- notably by promising a time (soon) where in order to be reimbursed for various services e.g. medicare a practice will have to file electronically.

As has been pointed out, although there are various (completely inadequate) standards for EMRs in play out there, "compatibility" is a low bar to clear and everybody adds their own bells and whistles, making any sort of switch between EMRs a major data port and conversion problem. Training and service, often as not, involves phone banks in India and opaque accents. Many/most of the EMRs have for all practical purposes no serious internal security -- no encryption of connections, trivial authentication, and rely on vpns and control of the internal network for security. Of course HIPAA provides no useful security guidelines in the first place, so the more you can make security someone else's problem, the more profitable your EMR is. In general, scaling of EMRs is poor (with a few large scale hospital-based exceptions) and they are, of course, enormously Windows-centric because that too makes a lot of things somebody else's problems. Such as security, installation, cost, scalability...

It's really quite sad. EMRs "should" make medical practice much more efficient and facilitate a large portion of the enormous burden of documenting everything in real time for physicians, in addition to facilitating billing and insurance claims and the overall practice financials and access to e.g. labs and other auxiliary services. Most do, to some extent, accomplish these goals. But they fall far, far, short of what they could accomplish, especially with a truly portable EMR interface that wasn't locked to any particular operating system and that had a "real" security layer in place. Having real standards and a federal cross-platform cross-application certification process would make things even better -- one could actually disconnect the user interface from the back end data and let users (e.g. physicians) choose the interface that suits them best across all vendors on any common database back end.

Too bad this will absolutely never happen...

rgb

This isn't just ICD-9/10, its the rest...

[Chitlenz]

What I think TFA is trying to express is NOT limited to ICD. That's a "low hanging fruit" which doesn't include the other coding enhancements required for EHR conformance. ICD is a way of expressing complains and maladies via a coded system so that everyone can understand it if it appears as a part of your public medical record. In other words, everyone has to say code xxxx1 = "breast cancer" so that when you show up in an ER 6 months after a diagnosis, they can tell what's going on. The elephant in the room isn't the malady descriptions, its the coding of procedural treatment (SNOMED-CT), laboratory procedures (LOINC), RX allocations (RXNORM and the NDF), and how its billed back to insurance (CPT), and more importantly how they interconnect.

We make EMR systems targeted towards radiology, and I can say with conviction that the whole CCHIT process has thrown GE and Siemens (and their ilk) into absolute chaos. They are, today, faced with fixing their old systems to be modern/conformant, and then trying to keep them updated going forward on a MUCH more aggressive maintenance schedule than they are used to. Oh, and every month that they can't do it, their customers will see as lost revenue from govt. reimbursements. Unenviable is an understatement, it will be a financial disaster for GE if they start losing people en masse to Epic and other new players.

As someone who makes "meaningful use" based systems, I can tell you its no joke to implement. CCHIT certification alone encompasses 25k pages of standards that have to be followed to the letter and proven via testing for qualification.

In a way, it's a strange twist that the big players (GE/Siemens/Merge) lobbied to make the qualifications as hard as they currently are in order to limit new competition, and are now sinking into the pit they themselves dug. Sick, but hilarious simultaneously.

ICD10 is The Phantom Menace

[Anonymous Coward]

Only half-joking there.

1. ICD is ridiculously comprensive as described. Also, it loses even some "human readable" sense. The old ICD9 codes at least were grouped by the body system...so you knew head injuries would at least be all in the 1xx.xx or something. The new ones are a jumble ONLY a computer lookup will do. CMS has crosswalks for free from ICD9 to ICD10 that get you most of the way there. http://www.cms.gov/ICD10/

2. The real point of all the KNOWN expensive stupidity in the healthcare system is to FORCE everybody to get bought up into a giant, Stalinist IDN (Integrated Delievery Network) eventually, so the gov't and big insurance, and big medicine can all keep huge $$$ without the pressure of real competition.

P.S. Gee...why is the AMA allowed to own and license the CPT's, the main billing codes of physicians? Why doesn't the gov't ever challenge the AMA and buy or make a new set? ICD9 and ICD9-CM are from the WHO...as is the DRG.

The healthcare system is a stupid stupid waste! There should be no such thing as a "non-profit" entity in medicine...you would see value and efficiency in about 30 secs if Docs and other peeps actually had to COMPETE for patients on the basis of value. Obama-care just entrenches the current wasteful system. It's sick.

Medical Software

[georgiawebguy]

As a former IT Admin for a medical clinic I can tell you that the medical software out there is generally outdated and usually running on older OS's and architectures. The doctors and other medical professionals want to do their jobs and not get bogged down in the technology. "If it works - don't fix it" is usually what they want - Not upgrading machines, software or anything else. Most of the time they point to the learning curve to teach people how to do things with new equipment (yes, some of the proprietary software out there is running -- still running -- on Win 98 and NT machines) or new software. Mandating EMR's (EHR) and "new" codes are good for patients for the most part. Unfortunately, Doctors and Software companies that supply them are very change resistant for a number of reasons.

Re:And it hurts too...

[postmodernistic]

Or... Goatse who cares? Internet made me insensitive.

The whole world or....?

[Anonymous Coward]

I work in health, ICD10 codes have been in for ages.
Depends what country you are talking about though, this could be Switzerland? not sure, the article is a disappointingly poor on details of location, pretty unfortunate for a news site....

Let gmhowell tell you all about himself

[Anonymous Coward]

A quote from the troll gmhowell says it all:

"I do whatever amuses me at the moment. Sometimes that is trolling. As far as AC? I only do that to avoid undoing moderations." - by gmhowell (26755) on Wednesday April 20, @12:49AM (#35877174) Homepage

Your own words prove to us that you're online trash gmhowell, you scumbag troll.

This IS why nobody here takes you seriously, or pays you any heed: You're a troll!

The above not enough? Well, here's more from you:

http://slashdot.org/comments.pl?sid=1907528&cid=34543612

And here also:

http://slashdot.org/comments.pl?sid=2087330&cid=35846218

("3 strikes, & you're out" - And, there's NO DENYING you are a troll, gmhowell. (Especially when you admitted it there in the links above, literally, in your own words!))

George M. Howell?

[Anonymous Coward]

George's a jerk in real life also. I know him. George M. Howell is just another dime a dozen web page flunkie http://www.google.com/search?hl=en&source=hp&q=George+M.+Howell&btnG=Google+Search who thinks he knows about computers. George M. Howell's a joke. Now that I see how he spends his time online bothering others I stand by what I said even moreso.