IMPLEMENTING ICD10CACCI Weighing in on the Canadian Experience The Expected and Unexpected

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IMPLEMENTING ICD-10CA/CCI Weighing in on the
Canadian Experience The Expected and Unexpected
 

• Gillian Price
• Chief Information Officer
• Winchester District Memorial Hospital
• August 5, 2009

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AGENDA

• The Canadian Experience Background / Context
• National Adoption and Approach
• Comparison of ICD9 -gt ICD10
• Expected Implications vs. Unexpected Outcomes
• Education Training / Human Resources
• Business Processes / Policies and Procedures
• Information Systems
• Patient Care Providers
• Decision Support / Clinical Informatics
• Timelines Budgets
• 8 Years Later 20/20 Vision

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Canadian Context
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Canadian Health Statistics

• North of the Border 13 Provinces / Territories
• Population 33 Million
• 50,000 doctors offices and clinics, and nearly
  1,000 hospitals.
• Approximately 2,000 healthcare transactions per
  minute in Canada
• Each year there are
• 440 million laboratory tests
• 382 million prescriptions
• 322 million office-based physician visits
• 35 million diagnostic images 2.8 million
  inpatient hospitalizations

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Context Timelines

• Our Canadian Health System is governed by various
  Federal governments and agencies who set the
  standards for our national healthcare system and
  information reporting.
• Canadian Institute for Health Information (CIHI)
  sets the overall guiding principles / standards
  for information reporting
• Operations / Management of our Canadian Health
  System is governed individually by each Province
  / Jurisdictions.
• 1995 - Canada committed to adopting the WHO ICD10
  
• 1999 Work began on the Canadian version of
  ICD10CA and included the Canadian Classification
  of Health Interventions (CCI) with European
  Informatics standards.
• 2001 Canada officially adopted ICD10CA/CCI
• 2001 2005 Provinces transitioned from ICD9 to
  ICD10 CA/CCI

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Provincial Transition

• As a result of each province being responsible
  for its own Operations / Management - they had
  control on when they actually moved forward on
  implementing the ICD10CA/CCI coding methodology.
  ICD10 CA/CCI was phased in over a 5 year
  period of time.
• Provinces that implemented early gave other
  provinces the opportunity to learn from their
  experiences.
• Early adopters
• East Cost Nova Scotia
• West Cost - British Columbia
• Late Adopters
• Ontario

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Comparison ICD9 Vs. ICD10

• ICD 9
• 5 digit numeric code
• No Laterality
• Coding is purely numeric with 3-4 digits with a
  decimal point after the second digit.
• Approximately 24,000 codes
• Dependency on Memory / Books and cheat sheets
• Interpretation of Guidelines

• ICD10
• 7 digit alphanumeric code with logical structure
  and decision trees
• Laterality R vs. L Appendages / Side of the body
• 7 Digits with no decimal point and starts with 3
  alpha characters.
• Approximately 150,000 codes
• Computer based application / Windows mouse work
• Implementation of Standards and rigorous
  evaluation of data integrity

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Education Training

• Expected Training and Education was going to
  be intensive and success would be contingent on
  the delivery / timing of the education and end
  user commitment. New classifications, new
  software and a new abstract
• Timelines for delivering education sessions
  varied by hospital, but the training approach was
  relatively consistent.
• CIHI Skill Assessment Questionnaire
• Self Learning packages from CIHI that
  demonstrated the comparisons between ICD 9 ,
  ICD9CM and ICD10CA
• Introduction to using a reference materials in an
  electronic format
• 1-2 day workshops with hands on training
• Online case studies for practice following an
  attendance workshop
• Follow up refresher courses in computer labs.

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Education Training

• Unexpected Outcomes - Vertical Learning curve
  ICD10
• CA/CCI is an electronic product and computer
  literacy is key.
• Mandatory training was not enough.
• Health Record Professionals (HRPs) need to
  obtain good basic understanding and familiarity
  of computers particularly windows training.
• HRPs needed to become more familiar with
  operative procedures and have a detailed
  knowledge of anatomy, physiology and
  interventions.
• HRPs were unfamiliar with alphabetical indexing
  and had to be re-trained on how to locate codes.
• HRPs had always relied on memorized codes and
  where now starting at ground zero.

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Human Resources

• Expected Change Management was key and we would
  need to
• rely on a traditional approach that would see us
  through the
• transition.
• Building readiness for change activities would
  ensure we had prepared the staff by
• Identify the operational changes and priorities
• Develop and provide tools to do the job
• Communication strategies to reduce fear and
  resistance to change
• Engaged the frontline users / stakeholders to
  ensure a smoother transition
• Promote the changes as a positive rather than a
  negative

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Human Resources

• Unexpected Outcomes Not everyone was prepared
  to learn
• something new to make the transition. Given the
  average age of
• HRPs at the time of the transition (40-50 Year
  of age Females) the
• HRP workforce experienced a premature shortage of
  health record
• professionals.
• Sick time overtime costs increased
• Staff took early retirements or jobs in other
  departments Vacancies
• Unionized environments became problematic as
  staff where being asked to upgrade their skills
  and work longer hours due to mandatory training.
• Backlogs increased due to staff vacancies and
  sick time.
• Reporting deadlines to CIHI were not met.

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Human Resources

• Unexpected Outcomes Continued
• Although there was initial discouragement.
  Significant Improves were reported within a 6
  8 week period. Confidence grew and a positive
  attitude and renewed interest in the profession
  emerged.
• Staff took responsibility for their continuing
  education a sense of ownership and pride
• The job was now interesting and exciting 20
  years of memorized codes Staff were developing
  critical thinking skills.
• Stronger staff took on the role of mentor with
  other staff and it became a very positive /
  health learning environment.

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Business Processes

• Expected Take a systematic approach to identify
  all business
• process both departmental and organization wide
  and map all
• information flow, inventory all reports and
  departments that would be
• impacted by the changes.
• Departmental Implications
• Coding backlogs / Drop in productivity
• Approach to coding from completed records which
  meant a change in processing of the records
• i.e Chart Deficiencies,
• Initial increase of Quantitative Qualitative
  Analysis processes frequency/focus.
• Delay in reporting to CIHI Request for
  relaxing timelines
• Forms would need to be changed to include
  additional information to capture specific
  information
• Moving from a paper-based process to a electronic
  information system Folio -view
• Organizational Implications
• Delay in providing statistical information to the
  Finance Department / Administration etc.
• Physician Billing / Workload Reporting / Research
  Projects / Risk Management and or CQI Projects
• Initial validity and reliability of information
  would be questionable
• Delay in meeting our external reporting
  requirements

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Business Processes

• Unexpected Outcomes As business process were
  reviewed,
• variation in practices, process redundancies, and
  inefficiencies
• where identified. Magnitude of change was
  underestimated.
• The investigation and development of detailed
  workflow plans revealed
• How complex the plan needed to be to accommodate
  new process changes
• How inefficient departments had become over time
  Many unnecessary workarounds
• Variation in staffing practices increased
  inefficiencies and identified redundant processes
  contributed to increase operational costs
• Assumptions had been made as to how the
  organization interacted and depended on the
  health information.
• Overwhelming feeling of how much impact this
  would have on the staffs daily routines.
  Nothing would be routine again!

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Business Processes

• Groundwork required
• Produce integrated workflow diagrams and design
  out redundant steps to streamline processes
• Map all of the department and organizational
  information flow
• Re-alignment of reporting cycles and various
  timelines i.e physician deficiency timelines
  conflicted with reporting timelines to CIHI.
• Universal chart order changes may be required to
  help locate information in the patients record.
• Look at redesigning clinical forms to flag
  physicians to document specific details.
• Inventory all departmental and organizational
  reports that will be impacted by the changes

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Policies and Procedures

• If you are going to change your procedure,
  timelines and
• expectations of staff /stakeholders and or
  committees all of your
• policies will need to be reviewed and re-written.
  Including Job
• Descriptions
• Changes in policies and procedures in any
  organization take time and commitment to execute
• Individual / Operational / Tactical Strategic
  (Board Level)
• No department will be left untouched
• Nursing
• Physicians
• Finance
• Diagnostics and Therapeutics
• Clinical Programs

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Information Systems / Technology

• Expected A need to leverage the technology to
  minimize the
• workload impacts and to build in data quality
  checks to ensure
• loss of data integrity was minimized.
• Increase of IT dependency during initial stages
  of implementation
• Increase in communication and dependency on
  Vendors
• Increase in cost of hardware and software
• Intensive testing to ensure compatibility of
  various reference tables
• Initial trial and error - version upgrades to
  address unexpected glitches
• Data Quality checking would need to be built in
  at various levels
• Maintain manual processes just in case of down
  time environment could initially be unstable.

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Information Systems / Technology

• Unexpected Outcomes - Underestimation of how
  much work was
• involved in preparing for the new technology
  environment and what
• additional cost would be incurred.
• I.T Departments were not prepared for the
  increased demand on their time and often lacked
  the expertise.
• Budgets for Hardware and Software were
  underestimated
• Example Coders required 2 monitors (15 inch
  changed to 17 inch) which would allow them to
  code and abstract on one while accessing online
  educational materials to assist them this
  avoids the toggling between screens which will
  delay the process and reduce productivities.
• Testing, testing, testing, testing increased
  the need for communication between Vendors, CIHI
  and Hospitals. - Collaboration is key.
• Compatibility of Old technology vs. New
  technology Upgrading
• Data Quality checking became a constant task for
  all hospitals and remains to this day.

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Timelines Budgets

• Expected Timelines would be aggressive but
  could be controlled
• and an increase in budgets for both operational
  and capital would
• be unavoidable.
• Timeline from beginning to end would take
  approximately 6 8 months.
• Aggressive timeline would have to be closely
  managed and additional timeframes would allow for
  any unexpected situations / issues.
• Increase in Hardware and Software costs needed to
  be built into the budget in the previous fiscal
  year and tracked as a separate budget item.
• Increase in Human Resource costs had to be
  estimated

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Timelines Budgets

• Unexpected Outcomes Both Timelines and Budgets
  were
• grossly underestimated due to unavoidable delays
  and unknown
• variables that were not planned / anticipated.
• Preliminary testing of various abstracting
  software vendors had difficulty with the
  integration with the Folio InfoBase product.
• Major functionality changes for the new
  abstracting software were identified.
• Timelines for implementation were in a fluid
  state delays resulted in increased costs and
  maintaining new skill sets proved to be difficult
  resulting in additional training costs.
• Hospitals report up to 2 years to implement.
• Additional costs incurred due to interfacing into
  3rd party software.
• Upgrading of existing systems to ensure
  functionality of new software an conversion fees.
• Hospitals report budget overages between 15 30

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Patient Care Providers

• Expected Physicians where the largest group of
  care providers
• who would require the most education as the HRPs
  were dependant
• on the detail of their documentation. Physician
  buy-in was paramount.
• Education Outlined Required
• An overview of ICD10CA / CCI
• Why the change in classification systems
• Benefits from implementing new national standards
• What can ICD10CA/CCI offer Physicians
• Documentation requirements to facilitate coding
• Relevant examples i.e Surgical / Medicine etc.
• Improved Communication
• Frequency
• Method
• New forms/tools
• New reporting requirements for Physician
  utilization profiles

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Patient Care Providers

• Unexpected Outcomes The need for granular
  detail in care provider
• documentation was met with mixed response, but
  overall well received.
• Dictation and transcription systems would need to
  be considered.
• Physicians were interested what the changes would
  do for them both
• from a negative perspective and a positive
  perspective.
• Ensuring physicians were part of the process
  resulted in a much
• smoother transition.
• Physicians welcomed the opportunity to be part of
  the solution and
• offered a variety of sound recommendations.
  Examples include-
• Coder Query Letters
• Coders participating in Medical / Surgical
  rounds
• Incorporating changes in the Dictation and
  Transcription systems to prompt physicians to
  include specific details. I.e Dictation
  Templates.
• Physician billing systems in Ontario (OHIP) use
  ICD9 to this day
• Major work around for them to convert ICD10
  codes back to ICD9 for billing.

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Decision Support / Clinical Informatics

• Expected The impact of implementing ICD10CA/CCI
  would not be felt
• immediately time delay due to reporting cycles.
  In-depth investigation
• required to determine the far reaching
  implications and upfront workloads
• would be required to mitigate the risk missing
  reporting deadlines and
• maintaining existing reporting levels.
• Benefits would Include
• A Single National set of Standards
• Comprehensive Scope of Data Sets
• Improved Specificity
• More effective, structure and presentation of
  Data
• Improved National and International comparability
• Ongoing maintenance and updating A mechanism to
  improve / future enhancements to potentially
  avoid upgrading to ICD11.
• Opportunity to improve health information and
  disease management
• Robust data environment for research

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Decision Support / Clinical Informatics

• Unexpected Initially there were significant
  comparability and grouping
• methodologies issues. All Decision Support
  Reports needed to be
• scrubbed for any traces of ICD9 old data
  collection and abstracting elements.
• Reports had to be rewritten to accommodate the
  new classification system.
• Field sizes needed to be changed due to character
  lengths of the diagnosis codes increasing.
• Report Descriptors needed to be changed as year
  to year comparisons were not possible
• Readmission information descriptors changed
• Left Without Being Seen Information for NACRS
  changed.
• ICD10CA did not have PLOS values instead, the
  ELOS values were used to determine overall
  averages and on a percentile basis. ELOS rates
  tended to be more generous which meant
  comparability from the previous years was not
  possible.
• Reports were delayed Case weights and length of
  stay national databases where void of comparable
  information from the ICD10 database. Report /
  Data reliability and integrity was questionable

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Immediate Impact

• Increase in job vacancies at both the staffing
  level and leadership level, overtime, sick time,
  grievances
• High staff turnover
• Project timelines were extended impacting
  departmental and organizational budgets.
• Decrease in Coders productivity due to learning
  curve. Productivity levels varied across the
  country. 23 - 50 loss in productivity
  reported.
• Took almost 1 year after implementing ICD10
  CA-CCI to regain some degree of stability.
• Immediate evidence of HRPs skill mix obvious
  division between critical thinkers and rote
  learners.
• Data quality suspect for first 6 12 months. No
  comparability

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Long Term Impact

• Productivity Coders never fully returned to
  previous levels A lot of information to
  assimilate due to specificity and increased
  number of codes.
• Ongoing costs related to in Human Resources /
  Information Technology / Operational Costs
• Constant state of change requiring ongoing
  education
• Constantly improving/ upgrading technology
• Data Quality reviews and introduction of new
  coding guidelines are part of our everyday
  routine.
• ICD9 still used for Physician OHIP billing
  -continues to be problematic.
• More robust clinical information environment
  which ultimately increase the number of requests
  for information from Decision Support Departments
  
• Disease Management we are learning so much more
  as a result of the data specificity.
• Greater accountability by staff, departments and
  organizations.

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8 years later 20/20

• What advice would we give to you?
• Get commitment from Leadership to make this an
  organizational priority not just a departmental
  priority
• Establish an interdisciplinary project team
• Establish a comprehensive project plan take
  advantage of software i.e Microsoft Office
  Project Planning
• Perform in-depth workflow evaluations and
  eliminate any human or technical barriers. Visio
  diagrams are very helpful.
• Establish a Strategic Education Plan You need
  to go over and above the mandatory training to
  get good results.

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8 years later 20/20

• Establish a Communication Plan and communicate
  project status regularly
• Start preparing and planning well in advance of
  your ICD-10 implementation. Allow for delays.
• If you have a budget add 25 more. Establish a
  separate project budget to track costs.
• Include your IT departments at the beginning of
  the process
• Address coding backlogs in advance
• Collaborate with Colleagues in your region /
  formalize regional committees to look at systemic
  impacts and issues resulting from the
  implementation of ICD-10. - Share your lessons.

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Conclusion

• Overall the transition from ICD9 to ICD 10 CA/CCI
  was a great success.
• The long term benefits outweighed all of the hard
  work, frustration, and
• disruption associated with the transition from
  ICD9 to ICD 10 CA/CCI.
• If you ask a Canadian Health Record Professional
  today... Would you
• return to the old ICD9- classification
  methodology?
• The majority of them would tell you that their
  job is so much more
• interesting and the change has been a positive
  influence on their careers.

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IMPLEMENTING ICD-10CA/CCI QUESTION PERIOD 
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• See you next year!
• August 7-10, 2010
• Washington, DC