This report originally appeared in the May 2011 issue of DOTmed Business News

By Isam Habboush

Health care in the United States is entering a new era of accountability. Health systems are under pressure to optimize clinical documentation practices to align reimbursement with delivered care and clinical outcomes. The impending migration to ICD-10 in 2013 is one manifestation of the expanding complexity of government and private payers’ clinical documentation rules and regulations.

The impact of the transition to ICD-10 is widely expected to be invasive, costly and challenging and is frequently described as the “Y2K bug” of the health care IT industry. The Y2K bug had a huge impact on the banking and financial industries, requiring expensive upgrades to most infrastructure systems. Most people probably still remember the worldwide anxiety as the minutes ticked away towards that one particular midnight over a decade ago. Fortunately, disaster did not strike.

The transition to ICD-10 is likely to be highly disruptive to the U.S. health care system, if not managed carefully using the right mix of tools, training and processes.



While the Y2K bug forced organizations to upgrade systems with software that could handle two extra digits in the year format, there were little changes to processes, training or work habits. In contrast, ICD-10 will require not only expensive upgrades, but also modifications throughout the entire clinical documentation, coding and billing value chain.

The challenges of ICD-10
Organizations will have to train health information management, clinical document improvement, case management, billing, quality and auditing staff on ICD-10 to ensure coding is performed correctly, and accurately reflects clinical information. Industry experts suggest the steep learning curve associated with the new coding standard may cause as much as a 50 percent initial drop in the productivity of medical coders, even after all the tools and systems are upgraded.

Most importantly, physicians will need special training to document with the additional specificity required by ICD-10. For example, documenting the phrase, chronic heart failure will no longer be sufficient. With ICD-10, physicians must also specify systolic, diastolic or both, and the acuity level. Similarly, instead of respiratory distress, physicians must explicitly state acuity level. These are just simple examples - real-life documentation needs are even more complex.

Improving clinical documentation programs
The immediate industry reaction will be to leverage CDI programs. While these programs have demonstrated their usefulness, the industry’s transition to ICD-10 will call for program changes to better align CDI operations with the new coding infrastructure. This will require resources for planning and strategy, as well as for training, implementation and operation.

CDI programs have improved overall documentation quality and affecting Case Mix Index with demonstrated enhancements to revenues. Typically, CDI programs focus training for physicians and coding and case management staff, and establishing processes to manage and track physician queries. They rely heavily on trained specialists to monitor physician documentation continuously and to intervene when necessary so there are no informational gaps.

The success of any CDI program depends on physicians’ acceptance and willingness to respond to CDI staff queries for more information. Unfortunately, several informal surveys and industry reviews suggest physicians view these queries as highly disruptive to their workflow and, as a result, are inclined to ignore them. Furthermore, while the goal is to achieve concurrent queries (e.g., during a hospital stay), some may arrive after the physician has already signed the chart. In these instances, the physicians are less likely to alter their notes, further reducing the effectiveness of CDI initiatives.

As we transition to ICD-10, a great deal of information might be lost from physician documentation. This will result in a drastic increase in the volume and frequency of physician queries by CDI specialists, leading to increased disruption in physicians’ workflow and, potentially, greater frustration for all.

So, can CDI programs alone meet the challenge for physicians and help facilities in the transition to ICD-10? The answer is a qualified yes, if organizations apply sufficient human, financial and technical resources and capture enough of physicians’ time to accommodate an increase in documentation.

Computer-based automated systems may hold the answer to ICD-10
In many industries, computerized expert systems have served successfully as automated assistants, executing tedious and repetitive tasks while human experts focus on creative work. Such technologies are quickly becoming indispensable.

For example, computer-assisted editing is another name for the commonly used spell-checkers in most popular word processing programs. In health care, computer-assisted detection helps radiologists find miniscule lesions in breast images to help increase screening sensitivity and accuracy. Computer-assisted surgery uses 3-D imaging and virtual reality tools to facilitate pre-surgical planning and to guide or perform surgical interventions.

Similarly, computer-assisted coding enhances productivity and workflow of medical coders. Incidentally, many industry analysts view CAC as a key tool for helping medical coders transition to ICD-10 coding.

Physician documentation is one of the next obvious frontiers for computer-assisted enhancements, especially in light of the impending transition. With optimally designed systems, physicians can document more efficiently and completely without having to jeopardize quality or be disrupted with information queries.

Computer-assisted physician documentation, or CAPD, must be able to accept physician documentation, which is overwhelmingly spoken narrative, without dramatically altering the physicians’ workflow.

In order to be successful, CAPD will need to be able to understand clinical narrative and leverage an extensive and up-to-date knowledge base of CDI guidelines and coding requirements.

Conceptually, the system should function similarly to a very sophisticated spelling or grammar-checker, continuously monitoring physicians’ documentation and, when necessary, prompting for clarification or additional information.

CAPD systems could revolutionize documentation and coding, holding the promise of reducing the burden of the ICD-10 transition on physicians and staff. However, a number of significant challenges must be addressed before CAPD could become a reality and be adopted into routine use by physicians.

Like other computer-assisted platforms, if not designed correctly, CAPD could lead to alert fatigue, which could result in physicians overlooking or ignoring the automated prompts or feedback. Therefore, CAPD must be designed to prompt for additional information only when it is absolutely necessary. It must intelligently analyze the entire content of the patient medical record to find clues before unnecessarily prompting for information already available in other parts of the document. Furthermore, CAPD must learn from experience and customize performance to the unique styles and habits of individual users.

While the concept is very intriguing and holds considerable promise, we must be careful not to position CAPD systems as the single solution for clinical documentation challenges. Rather, they should be viewed as an additional tool to enhance documentation and need to be considered in the context of an integrated and comprehensive CDI program. When used correctly, CAPD can support and sustain internal efforts to improve clinical documentation and to ensure appropriate reimbursement and more accurate quality reporting.

Isam Habboush is the director of product management at Nuance Communications, Inc.