“This opportunity will allow Dolbey and Adventist Health System to prove computer-assisted coding’s efficiencies and results in one of the most successful health systems. Adventist Health System’s senior leadership has a vision of new, inventive ways that computer-assisted coding can positively impact not just the coding and billing process for revenue but to proactively drive precise patient care for quality outcomes,” states Chris Casto, Vice President of Dolbey Systems.

Elliott Familant, chief architect of the NLP technology that drives Fusion CAC, states, “Adventist Health System has seen a great potential in Fusion CAC for automating coding workflow, pre- and post-auditing of coding events, increasing productivity of human coders and providing tools to all levels of healthcare case management.”

Fusion computer-assisted coding technology is one component of an integrated Health Information Management Fusion Suite offered by Dolbey to healthcare that also includes Fusion Voice for dictation management, Fusion Text for transcription and document management and Fusion Expert and Speech for both front-end and back-end speech recognition for healthcare.

About Adventist Health System

Adventist Health System is a not-for-profit healthcare organization that emphasizes Christ at the center of care. Founded in 1973 to support and strengthen Seventh-day Adventist healthcare organizations in the Southern and Southwestern regions of the United States, Adventist Health System has quickly grown to become the largest not-for-profit Protestant healthcare provider in the nation.

Today, Adventist Health System supports 33 hospitals. Adventist Health System’s flagship, Florida Hospital is one of the largest healthcare providers in America and a national leader in cardiac care. Established in 1908, Florida Hospital now includes almost 2,200 beds on seven campuses. Florida Hospital is dedicated to improving lives not only in Central Florida, but also around the world. As a destination hospital, it is committed to serving the healthcare needs of its patients with a holistic approach to heal the mind, body and spirit, striving to be the hospital of choice for patients, physicians and employees. Visit http://www.adventisthealthsystem.com/ for more information.

About Dolbey

Dolbey’s innovative technologies share a long and proud history. In 1914 John Dolbey formed a partnership with Thomas A. Edison to make available the earliest dictation inventions to the business community. During the 20th century, as dictation evolved from the wax cylinder to today’s digital recording, Dolbey & Company, Inc. successfully navigated these revolutionary changes.

In the mid-1980s Dolbey & Company began developing its own medical transcription and document management software, laying the groundwork for today’s robust suite of Fusion Text® and Fusion Speech® transcription and speech recognition products and modules. In 1994 Dolbey Systems, Inc., was formed and became a close partner, concentrating on dictation and coding systems. Dolbey Systems’ Fusion Voice® and Fusion CAC® have become integral parts of the Fusion Suite™ of products.

Together, the Dolbey companies have built an integrated solution for dictation, transcription, speech recognition, document management, and computer-assisted coding. Our solutions focus on providing solutions that assist in managing the collaborative workflow process in healthcare from over 40 authorized sales, service and support centers nationwide. Visit http://www.dolbey.com/ for more information.

Computer-assisted coding won’t eliminate the profession, but it will change it dramatically.

Mythily Srinivasan thought she was out of a job. Out with human coders, in with computer-generated coding. At first that seemed to be her facility’s master plan.

When word first came to Srinivasan, CCS, and her fellow coders that the Robert Wood Johnson University Hospital in New Hampshire was implementing computer-assisted coding (CAC), they feared the worst.

“Like everybody else, I thought, ‘Oh my god, is it going to come and am I going to be replaced?” says Srinivasan, now the coding manager at the hospital and a 17-year coding veteran.

With its implementation in spring 2006, what Srinivasan soon found out was that CAC secured her job and made it better. Her fear soon melted into appreciation for a technology
that has eliminated some of the mundane coding tasks and in turn enabled her to better use her unique skills.

“Now [coders] are very comfortable with CAC, because you really need manpower to evaluate the codes [and] ensure they are coded correctly and according to the guidelines,” Srinivasan says. “There was a lot of input from the coders when we initially started this. And I think it allowed the coders to see that their coding knowledge base and judgment was critical to the coding process [and] that the system was truly an aid.”

With more and more healthcare facilities implementing CAC, many coders are wondering what the future holds for their profession. Some have a similar first impression as Srinivasan—computers will eliminate humans.

Some coding positions are at risk of deletion. Others will require an increased emphasis on advanced skills. But several HIM experts say coding professionals will always be in demand, no matter how advanced the technology becomes.

A Twilight for Routine Coding

Layoffs in the coding department are a possibility due to CAC. But the first jobs to be cut are typically bottom-tier positions that are difficult to fill, even when there isn’t a coding shortage, says Becky DeGrosky, RHIT, a former coding manager and current product owner, clinical products at Accuro Healthcare Solutions, based in Dallas.

That includes outpatient radiology coding and GI lab coding. Most organizations introduce CAC in radiology, due to the high volume and highly standardized documentation generated there.

But the technology is never going to replace jobs that require analytical skills, DeGrosky believes. “There are two levels of coders in my mind,” she says. “There are the real coders, they are like hen’s teeth, they are very hard to come by. These are the people that actually read the record and make the decision not just what codes to assign but ‘what am I supposed to be coding here.’”

This type of coder holds different skills than those who are coding primarily for billing purposes on routine procedures. The latter code “for radiology, the cath lab, the GI lab—those are the kind of folks that computer-assisted coding is going to definitely replace,” she says. However, that time is still several years off, and as good as the technology is right now, no system is being granted unmonitored coding rights.

Security in Learning

Radiology coders and others affected by CAC can move to new roles, if they are professionally versatile. In general, the more educated a person is on coding, DeGrosky says, the safer his or her job is.

That doesn’t necessarily mean people must rush back to school. Some coders express worry that CAC will require them to get formal degrees to keep their job. DeGrosky believes properly trained coding professionals who keep up on their credentials already have most of the formal education they will ever need to work beside CAC. However, as the industry changes, coders may need to brush up on their schooling.

Coders will most likely need to hone the coding skill that makes them unique as humans—critical thinking. Understanding disease processes and pharmacology, and having sound familiarity with anatomy and body systems will ensure coding professionals have their place alongside coding technology, according to Cecilia G. Hilerio, RHIT.

Hilerio, director of health information services at Robert Wood Johnson University Hospital, says that coders will require this knowledge as their role transitions to coding oversight specialists. This education will come from both in-house training and formal schooling.

“I think that the coder is going to have to be very keen on investigating further into the medical record, whether it is a hybrid record or a complete electronic record,” Hilerio says.

In the Near-term, Automating the Grunt Work

CAC codes procedures that many people currently don’t want to do. That was the experience at Massachusetts General Physicians Organization in Boston, a subsidiary of Massachusetts General Hospital.

In 2001 the facility instituted a CAC program in its radiology department because the facility couldn’t retain coders to do the work. “We had a backlog of exams, and we had a difficult time retaining qualified coders to do that type of coding,” relates Gloria Johnston, MBA, RN, CCS-P, CPC.

Johnston, a former associate director of coding for the organization, worked at the facility during the CAC implementation. The coding that CAC now performs “was just really boring work,” Johnston says. “We initially thought we could supplement our staffing by using the computer-assisted coding to code the boring stuff, then we could have our coders work on the more complex stuff.”

That happened, but there was an added benefit, Johnston said. Once coders were trained on the new CAC workflow, their productivity increased. CAC didn’t lead to any reductions in staff, instead it filled the perpetual staffing holes.

The technology makes life easier for a coder, Hilerio says. “I think this is really going to help coders, period,” she says.

CAC is good for the industry, agrees DeGrosky, because it saves the grunt work for the machine and enables coding professionals to turn their skills to more complex coding cases. “Assigning the same code to 100 charts over and over—who wants to do that?” she asks. “For a lot of people, this is going to provide them with an opportunity to shine.”

Shasha Graham, CPC, was skeptical at first when her facility implemented CAC. In fact, coders at Shands at the University of Florida feared the worst when it was announced that the radiology department was implementing CAC in July 2005.

“One of the first things that went through our heads when our manager told us we were going to implement [CAC] was, ‘Oh my god, we are going to lose our jobs,’” Graham says. “‘They are going to put in this machine that will do our coding—what are we going to do?’”

Graham says she soon realized that CAC would improve her job and enable her to better use her coding knowledge.

“A lot of coders are afraid that by getting CAC their job is in jeopardy,” she says. “But by having CAC, our jobs aren’t going anywhere. We still have as many coders now as we did when we started this two years ago.”

That’s not the larger plan, however. Managers at Shands told Graham and her fellow coders up front that part of the program’s goal is to eventually reduce the number of coders on staff.

That reduction “is not now, and it is not tomorrow,” Graham says. She believes the cuts will come eventually, but thinks it could be five or seven years before they do. “There is no timeframe,” she says.

After initial training to learn how to work with the CAC system, Graham required no additional training to do her new job. Everything she learned through her coding certification still applied, she says.

Transitioning to New Roles

A lot of Graham’s time is spent approving codes that the program assigns. Because approving codes for standard cases takes less time than manually assigning them, she has more time to devote to other aspects of her job as a quality assurance coder, including handling rejections and educating physicians on proper documentation.

When CAC was first implemented, Graham spent a lot of time helping train the program on proper procedures. Taking part in this process demonstrated the need for human expertise in coding, she says. She uses an example of coding a complete versus a limited ultrasound of the abdomen. The program may “code it out as complete, and you read in the notes that all eight of the components are not coded, then you change it.”

Once the program is adequately trained and reliable enough to code cases, Graham still needs to approve the assigned codes. Coding programs will never stop learning and will never stop needing humans to help train them, Johnston says. Reviewing the output is an essential part of the technology.

At Shands, Graham says CAC advanced the coder roles by allowing coders to work on different coding queues according to their expertise. When CAC was first implemented, the only thing that came through the program were plain films, which the entire coding team shared at the time. But as more and more was put through the program, like “fluros and ultrasound and mammos and CT and nuclear meds,” coding professionals started to handle reviews differently, she says.

“Some people stayed on the plain films, and then the more established coders were moved up to the harder areas,” Graham says. “You could learn the area and find your specialty.” This made for a more mentally challenging and, in turn, rewarding work atmosphere, she says.

CAC also helps eliminate the strain of perpetually backlogged cases and aids coders in catching inconsistencies and inaccuracies, she says. Being able to do better work each day led to more job satisfaction. “If anything, [CAC] helps. You have more time to do other things,” Graham says. “You are coding it out, seeing everything, and that is something to be proud of in a way.”

The implementation of CAC at Mass General, along with a workflow redesign, allowed coders to move from the hospital’s backroom to their homes and telework. “The coders had improved satisfaction and morale,” Johnston says. “They in turn became integrated with the department, became the experts in the department, and became involved in developing their protocols. So really a much more expanded role for the coder.”

Kristie Thibault, CPC, says CAC had a positive effect on her job. Now the leader of the ancillary coding team at Mass General, Thibault was present when CAC was implemented for plain x-rays and mammography in 2001. No one was sure what was going to happen, and some feared for their jobs. But fears were put to rest when they saw how it would improve their work.

“I was ecstatic, because we had an old system that was very un-user friendly,” Thibault says. It took time for the program to get up to speed. Once implemented, any reservations she held diminished when she saw the need for human interaction.

“It was not even two weeks into the program and [the coding staff] knew we had very good job security,” she says. They saw that the new technology was not going to “take over.” Radiology coders were able to move up to more advanced cases, like neurosurgery and vascular surgery, and had more time to query physicians.

Not everyone wants those “higher” coding roles, of course. For some, the opportunity to expand their role isn’t a big enough draw to embrace change. Still, even those stubborn in their ways are not at risk of CAC taking their job just yet.

But change is a part of life, DeGrosky says, evident by the file clerks who lost their jobs after hospitals adopted paperless medical records. In order to avoid becoming outdated, coders must pay attention to the times and stay at the forefront of the profession, she recommends.

Help Needed: Human

CAC at Shands leaves plenty of work for coders, Graham says. After all, the program can’t run and find additional information. “It can only go off the information that it found on that particular reading,” Graham says. “So you still have a lot of research to do as far as getting the procedures coded correctly and paid for.”

Healthcare organizations should not purchase a CAC product and expect it to replace coders. Vendors are usually careful not to promise such a thing, DeGrosky says.

No matter how advanced CAC becomes, healthcare facilities will still require skilled coders to implement, train, monitor, and audit computer-generated codes, according to Johnston. “Until the day comes that our nation’s healthcare system changes such that detailed health information becomes unnecessary, we are always going to need this process,” she says. “Without humans, there is really no way to ensure that accurate coding information is being assigned, whether it is assigned by a human or by the computer.”

“The computer can only do so much,” DeGrosky agrees. “These coders are still going to be needed, they are just going to be in a different role, an advisory role to the computer.”

Though the coding profession will remain essential, that doesn’t mean coders shouldn’t emphasize their worth when CAC is implemented at their facility. Coders need to work through the implementation process and “lay claim to their turf,” DeGrosky says. “Say, ‘Here is where I know I’m the expert.’”

The most important thing when it comes to any change is that HIM managers provide adequate information to their coding staff about the future. “How will this change my job?” is a big question that needs to be addressed from the beginning, Graham says. “New things are scary. It was intimidating at first, but once we started doing it we were like, ‘Wow, this is pretty cool.’”

Chris Dimick (chris.dimick@ahima.org) is staff writer at the Journal of AHIMA.

Computer assisted coding enthusiasts believe it is the ticket to a streamlined coding process, with efficient

and accurate coding at a fraction of the price. Others fear it’s the end of professional coding as we know it;

and coders will have to adapt as computer software replaces job duties. Whether you see the glass half full

or half empty, your best bet is to understand the options that are in front of you.

How will CAC impact the ICD-10-CM transition, the coding process, the accuracy of coding, and the future

responsibilities of coders?

Will Software Complicate ICD-10-CM Transition?

The good news is that CAC and electronic health records may smooth the transition from ICD-9-CM to

ICD-10-CM. Computer application manufacturer e-MDs’ president, Michael Stearns, MD, CPC, is already

planning for ICD-10-CM implementation. Stearns said “We have an embedded terminology called the

Medicapaedia that is mapped to ICD-9-CM, ICD 10-CM, or any other terminology. This year, we will add

ICD-10-CM to prepare for use of our EHR in other countries. This allows for a seamless migration when

ICD-10-CM is required in the United States.”

Dean Tullis, president and CEO of Voice Products’ Fusion CAC, developed by Artificial Medical Intelligence,

said his company is working with hospitals already using ICD-10-CM in the countries of Canada and Brazil.

“We will provide an easy transition when and if the time arises for this coding system to become

standardized in the United States. The software model allows the ICD-9-CM and ICD-10-CM dictionaries to

be cross-walked and then tuned accordingly,” he told

Garbage in; garbage out. Because coding is a highly variable task, the error percentage rate with CAC is

also variable. There are factors affecting correct coding on the coding level and the reimbursement level.

Coding error percentage rates using CAC depends on the facility’s or practice’s needs, Tullis said.

“Every institution has its own coding subtleties … [Our product] Fusion CAC is no better or worse than a

coder. As part of our installation, we can tune our engine to the particular facility. However, some facilities

prefer not to tune the engine, but would rather have the coders select the codes, adding, or deleting codes

as necessary. Fusion CAC is NOT a coding robot and therefore does not ascribe to the misnomer term of

coding accuracy.”

Stearns agrees that the percentage of coding errors using E-MD EHR is dependent on who is using it. He

said, “It varies by clinic, but practices with efficient processes in place typically get well above 95 percent

acceptance (a denied claims rate of less than 5 percent). Some practices achieve consistently high

acceptance ratings as indicated by e-MDs customers and frequent membership monitoring of e-MDs

customers.”

Will CAC replace certified coding professionals like robots replaced auto workers? Stearns said, “EHRs will

create new job opportunities for CPCs® in the area of pay-for-performance and related reporting activities,

which will soon be driving payment to a much higher degree. CPCs® will help practices by reviewing the

quality of automated coding support provided by the systems. It will also help auditors by increasing the

amount of information they can review, even from a remote location.”

Tullis said, “It is possible that coder responsibilities may change. Instead of being readers and procurers,

they will become reviewers and auditors. Coders will need to verify the codes within the documentation

and the system will require a level of human intervention, approval, and review. Many facilities work with a

hybrid medical record meaning they have paper records, progress notes, and legacy handwritten reports,

etc. We pre-code the chart components that reside in an electronic format but provide the means to enter

codes associated with the paper record, creating a single traceable chart record. Again, coders will need to

verify suggested codes and look at any handwritten data that doesn’t reside in electronic form.”

Anti-fraud software is a feature that many administrators are looking for; however, not all software has

this feature. When referring to Fusion CAC, Tullis confirmed the source documentation cannot be changed.

The codes suggested by Fusion CAC are the only component that can be altered at a coder’s discretion.

“Any time a code is changed, deleted, or added, a traceable log file is created noting the affected change

and the coder who made the change.

specific user, including when and what time the change was made, down to a tenth of a second. The

software also uses reverse mapping where accepted codes are traced back and highlighted within the

original source documentation.”

e-MDs system, however, doesn’t “have anti-fraud software labeled as such. There are strong audit trails

that keep track of transactions,” said Stearns.

This is very helpful as it tightens the controls on how money must be handled. For example, one of the

most common ways that money might be stolen from a system is the cash copayments received. There is

a function in place that immediately starts the tracking system such that someone cannot take a

copayment, hand-write a receipt, and then take the money. Even if the transaction is deleted, the record is

retained in the audit trails. Many financial reports can be run based on a number of criteria to help narrow

down and find the source of problems. For example, one might run a report by specific user and compare

it with other users. If it appears that there is an anomaly, then the audit trails will reveal the detail such as

a reduced charge from the defaults automatically set by the system from fee schedules.”

What Impacts Coders Most?

In the future, Tullis said, we will see “positive impacts in the form of increased coder and HIM efficiency

offsetting many of the new and future regulatory pressures on HIM. It will help the coders deal with new

regulations being implemented such as POA indicators.”

Stearns said, “Technology will provide clinicians with the ability to provide higher quality care by

identifying compliance with guidelines. Coders are perfectly positioned to take advantage of their

understanding of medical terminology to set up systems to automate quality reporting. Coders will be

required to learn about more sophisticated terminologies such as systematized nomenclature of medicine

clinical terms (SNOMED CT®), but the basic knowledge they need to know will be similar to ICD-9-CM.

They will also need tools to embed coded concepts within applications that can later capture structured

data.”

Copyright © 2009 American Academy of Professional Coders | 2480 South 3850 West, Suite B, Salt Lake City, Utah 84120

Every alteration, every action within Fusion CAC leaves a ‘paper trail.’ Everything can be tracked to aCoding Edge

• Rules-based, configured by site

 • Increased coding productivity

• Increased efficiency; frees professional from mundane tasks

• Comprehensive code assignment

• Consistent application of rules

• Electronic coding audit trail •

 How CAC can help with coding issues

Due to limited space, early registration is strongly encouraged. Click Here to Register!

Effective Oct. 1, 2008, Medicare successfully completed the 3-year transition from the previous diagnosis related group (DRG) payment system to the new Medicare severity DRG (MS-DRG) system. As noted in previous summaries, this new system is designed to better account for the severity of the patient’s disease.

As the MS-DRG reimbursement system becomes further entrenched in the daily operations of hospitals, HIM professionals must continuously update, improve and challenge their knowledge base to include more than just coding.

One of the most important steps is to improve your clinical knowledge of disease processes and manifestations. HIM coders who do so will find it easier to communicate with the medical staff regarding documentation issues, while continuing to follow official coding guidelines.

In his article titled “Positioning Your Facility for Severity Adjusted Coding” (Journal of AHIMA 78, no. 4, April 2007), Paul Whitaker states, “Coders must not only understand and apply official coding guidelines as published in Coding Clinic, they must know ICD-9-CM codes in depth. Unfamiliarity with V codes and traditionally insignificant diagnosis codes can sabotage a facility’s ability to receive proper reimbursement.”

Many coders are intimidated by the medical staff, so communication with them is often tense at best. However, increasingly, coding professionals are being asked to provide education to physicians, nursing and ancillary staff on the documentation requirements that impact code assignment and present on admission (POA) reporting. As a result it’s essential they tackle that intimidation head on and take the following steps, and others, to meet the challenge.

First, enlist the help of the medical director and/or department chiefs to assist in the development and implementation of an educational program. Provide a brief overview of the official coding guidelines so the medical staff understands the constraints placed on coders when assessing the data in the medical record to determine code assignment.

Next, discuss the query with physicians when addressing documentation and coding issues. As stated in the article titled “Managing an Effective Query Process” (Journal of AHIMA 79, no. 10, October 2008), “.querying has become a common communication and educational method to advocate proper documentation practices.”

Discuss the necessity of queries and what prompts a query to be sent to the physician. The Centers for Medicare and Medicaid Services and the Joint Commission state that physicians are expected to provide documentation of the patient’s health history, present illness and course of treatment that is legible, complete, clear, precise and consistent. If these documentation components are not met, a query may be sent to the physician for clarification. Provide specific case examples of incomplete documentation and how it impacted the code assignment and therefore the subsequent reimbursement, quality of care and reporting, and severity of illness.

Specifics of documentation should include the level of severity, etiologies of symptoms, anatomical site specificity and disease manifestations.

As we all know, health care is increasingly data-driven, requiring HIM professionals to shoulder a heavy load, which includes being in the middle between clinicians and the need to collect and process detailed clinical data. HIM coders must continue to look to the future, as changes to data collection and reporting will be constantly changing.

Susan Howe is a senior healthcare consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

Health information professionals looking to gain a sense of what lies ahead can learn a few lessons from how their Canadian counterparts approached the task

Meeting the Centers for Medicare & Medicaid Services’ (CMS) proposed plans to require full implementation of ICD-10 by 2011 will be neither cheap nor easy. According to a 2004 RAND report, prepared on behalf of Health and Human Services, the transition price tag will run anywhere from $425 million to $1.15 billion in one-time costs for system changes and training, plus an additional $5 million to $40 million per year in lost productivity.

But it is necessary for many reasons, including the fact that the United States is now the only industrialized nation that has not switched to an ICD-10–based classification system since the code set was first endorsed by the World Health Organization in 1990.

Canada, which completed its five-year transition in 2006, is often lauded for the proactive, highly strategic approach it took for the move to ICD-10-CA. As such, there may be a few pages the United States can take from its northern neighbor’s playbook to help ease its own transition.

Key Challenges in Canada
Canada began implementing both ICD-10-CA for morbidity coding and the Canadian Classification of Health Interventions (CCI) in 2001 following a development, product, and testing cycle that lasted approximately 12 months and a pilot program in New Brunswick.

In addition to significantly expanding code sets to achieve greater specificity, Canada also needed to create versions in English and French. But the greatest challenge did not come from the rapid deployment, code-set expansions, or even dual-language system development.

“The major change and challenge for Canada at the time was that, previously, coding books were books. They were paper,” says Mea Renahan, BScPT, MBA, CHE, manager of classification standards for the Canadian Institute for Health Information (CIHI). “These classifications were completely electronic, but not everyone had a computer on their desk with Windows capabilities. That was the first challenge … to computerize everyone and also to train people to go from DOS to a Windows environment.”

The second greatest challenge was educating coders on the rule changes created by the higher specificity level of ICD-10-CA and the concurrent introduction of the CCI. Exacerbating this particular challenge was the volume of codes HIM professionals would be dealing with, which expanded from 3,500 in the Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures to 20,000 in the CCI.

A third challenge was a shortage of professional coders—something with which the United States is very familiar—that made it difficult for some provinces to fill open positions. The resulting coding backlogs would only worsen as coders struggled to adjust to the new system.
 
The end result was an average learning curve of four to six months and an average of six months for productivity to return to pre–ICD-10-CA/CCI levels.

“One of the biggest problems was the resistance to change and the shortage of coders and health record professionals. Most of the coding previously was done by memory, which is true of the United States for many providers and facilities as well. It was difficult for the coders to unmemorize diagnosis codes,” says Deborah Grider, CPC-E/M, CPC-I, CPC-H, CPC-P, CCS-P, a healthcare consultant, an author for the American Medical Association, and president of the American Academy of Professional Coders National Advisory Board. “Many coders in Canada were familiar with abstracting software but were unfamiliar with Windows-based products. They were also unfamiliar with coding-lookup software, and many had not even used a mouse prior to implementation.”

Grider also notes that additional problems cropped up during implementation, including the need to manually maintain nontabular components such as front and back matter and tables, an SQL server incapable of efficiently handling coder demand, lost formatting, and delays throughout the iterative process of working with an external contractor.

Strategies for Success
To effectively manage what promised to be an exceptionally daunting task, the CIHI developed a comprehensive, four-phase plan for transitioning to ICD-10-CA and implementing the CCI.

It started with the preplanning phase, which was perhaps the most important element to the project’s success. This included the development of a comprehensive provincial plan that centered on the establishment of committees made up of key stakeholders in the process who served in either an advisory or task-based capacity. A provincial leader or project coordinator or team was tasked with overseeing the plan’s implementation, which started with an environmental assessment to identify needs and resource requirements, funding responsibilities and sources, and monitoring processes.

Success depended on gaining the early commitment to and engagement in the project from a broad range of industry stakeholders, including all levels of governments and their agencies, professional associations, colleges and universities, healthcare facilities, vendors, and the CIHI. Also critical was a transparent communication strategy for keeping everyone informed of progress, next steps, issues, and resolutions.

In addition to conducting a detailed computer-readiness evaluation focused on hardware, software, and computer literacy of end users, a robust education and training program component was designed to target the specific needs of each stakeholder group.
 
The CIHI took a three-pronged approach to education. First, it provided every facility and vendor with an implementation tool kit, a self-learning package, and a basic training workshop. The organization also trained individuals in each province to serve as trainers and resource personnel.

“CIHI trained every HIM professional in the country. … It was important that everyone understand what needed to happen in order to change from a numeric system to an alphanumeric system and also how to include the CCI,” says Renahan. “We tried to emphasize where the system had changed from a coding perspective and also to familiarize them with the search engine and Folio tools to get them comfortable with the search functionality of the product. We then had two days of hands-on, face-to-face [training] with our staff and provincial representatives.”

The CIHI also launched an online coding query service, where coders could post specific questions to the organization, review responses to other queries, and access resources to help them navigate the new system. The query service, which has since been expanded to encompass six databases and case-mix grouping methodologies, has in excess of 10,000 queries in its databank.

The second component of the CIHI’s plan was a testing phase, during which hardware and software were checked against the established deliverables and expected outputs, and a determination was made regarding the success of the education and training programs for end users.

Key activities in phase 2 included the establishment of procedures for measuring and reporting on the functionality and quality of the input and output and ensuring the availability of adequate in-house IT systems support, as well as technical and coding support for the coding staff. Also important were ongoing communications among the CIHI, vendors, and other stakeholders to ensure early detection and resolution of any problems and adequately prepare facilities for expected productivity dips.

The process entered phase 3 once the system was up and running and facilities were working to comply with provincial/territorial and CIHI submission deadlines. Again, communication was key—particularly among vendors, the CIHI, and end users—to continue identifying and resolving problems and share experiences with others undergoing the transition process.

The fourth and final phase—maintenance and upgrading—is ongoing. It is designed to encourage active participation in the process and ensure the integrity and value of ICD-10-CA and the CCI as tools to gather the information needed to guide future decisions regarding Canadians’ health and the country’s healthcare system as a whole.

Renahan notes that continuing education is a priority for the CIHI, which offers a range of e-learning programs, workshops, and annual case studies geared toward the concerns and challenges identified by coders and to emphasize the best use of classifications.
Although there were glitches and roadblocks, which are to be expected in a transition of this magnitude, the project was ultimately successful.

“Everyone was keen to do this. It was a challenge because it was a completely electronic environment, but once they got into it, no one would ever want to go back,” says Renahan. “From the coders’ perspective, they are thrilled to be able to code what they are seeing [in the chart] and to have much more in-depth information to work with.”

Differences Aside, Key Lessons for the United States
It is important to note that there are a number of critical differences between Canada and the United States that are likely to limit the lessons that can be culled from the former’s ICD-10 implementation experience.

Canada’s universal, single-payer healthcare system is funded, regulated, and managed by the federal government, unlike in the United States. As such, “They can make a centralized decision to change the system and make it much more easily,” says Robert Tennant, senior policy advisor with the Medical Group Management Association.

The Canadian government also footed the bill for the transition, including software and hardware upgrades and training HIM, coders, researchers, and clinicians. Implementation was also phased in over five years.

Meanwhile, the CMS is proposing that the system be transitioned by October 1, 2011, giving everyone less than three years to get up to speed. Further, the transition’s full costs will be funded by the private sector.

“But the critical difference is that Canada decided not to implement ICD-10-CA in the physician practice setting but rather focused strictly on the hospital setting. When asked about that decision, they said that it would have been too expensive and complicated and of only marginal value for public health data collection,” says Tennant.

Despite these differences, there are several key lessons U.S. healthcare leaders can learn from Canada’s experience. According to Grider, a few of the areas that went particularly well for Canada include the following:

• having a dedicated information systems staff to support the classification staff;

• the development of a custom JAVA application in Oracle developer that could be edited in XML in an unformatted text box or downloaded to a user-friendly XML editor;

• the use of Gantt charts and detailed work plans to help the transition go smoothly; and

• the development of a copy code edit tool to reduce key errors and search engines to enable high-speed searches.

“What did not go so well included that shadow files were not transferable with version 2002 and 2003,” she says. “Canada felt they needed to start sooner. There should have been a longer testing phase with more frequent meetings with expanded participation. The detailed work plan was too tight, and the timeline needed to be expanded.”

For Tennant, the pilot testing done by Canada was perhaps the most important step the country took that the United States should be but is not duplicating.
 
“No industry should ever go through a change of this magnitude without doing a pilot,” he says. “There are lots of positives that come from doing a pilot, not the least of which is the identification of problems and solutions.”

A pilot test could also answer key questions about the impact the transition will have on the different facets of the U.S. healthcare system, as well as determine whether there is real value in making the transition in both the inpatient and outpatient sectors at the same time.

“If Canada did their pilot and they did their analysis and found the value was only on the hospital side, that might be the most important lesson the U.S. can learn,” says Tennant. “I don’t want to come across as overly negative about ICD-10, but it’s one of those complex and costly changes where you are on a cliff and it’s foggy. Do you just jump and hope the ground isn’t that far away? Of course not.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.