Avoid ICD-10! Yes you can!

Lots of news/talk about ICD-10 these days.  Most organizations are spending time and money training care providers on it.  Software developers are busy implementing it - often by changing diagnosis selection search menus from ICD-9 to ICD-10.

They're missing a fantastic opportunity.

ICD-9-CM and ICD-10-CM are administrative coding systems.  They're used to code diagnoses. Clinicians have (unfortunately) been forced to learn many ICD-9 codes and are being told that we need to shift to ICD-10.  Some of our colleagues are hoping that they can just use ICD-9 and "someone else" will convert ICD-9 to ICD-10 but of course this can't happen.  ICD-10 is much more granular, and often requires additional information.  It's like the vet requiring one to specify your animal's breed:  ICD-9 allowed for "dog, cat, aardvark."  ICD-10 requires:  "Golden Retriever, Persian, O. a. lademanni ."  Nobody can translate to the more precise term if you hadn't recorded sufficient information in the first place.

"But how can we avoid ICD-10?  That's the title of your blog post!"  You say.  "How?  Why?"  ICD-10 (and ICD-9) are administrative coding systems, weren't designed by or for clinicians.  We don't think that way.  There are (much) better alternatives.  When ONC made SNOMED-CT required for recording diagnoses in certified EHRs in 2012 (effective for the 2014 certification criteria) I thought it would be obvious that the combination of SNOMED-CT for recording of diagnosis - combined with the free ICD-10 to SNOMED CT mapping tools that NLM published at the same time would meet the needs of organizations to RECORD SNOMED-CT and yet DELIVER ICD-10 to those who required it - primarily CMS and other payers.  Why capture SNOMED-CT and then (again) capture the same information in ICD-10?  I was sure that everyone would "get" the hint.  Commercial solutions like IMO and HLI offer even more elegant methods of capturing interface terms (terms that are customized to the user) and then mapping to the proper code:  SNOMED-CT for clinical data recording and transmission, and ICD-for administrative transactions.

It wasn't obvious.  Many (but not all) health IT developers ignored the opportunity to insulate clinicians once and for all from administrative codes.  Hospitals and other care delivery organizations spent millions on consultants to develop and implement training and "go-live" strategies to teach clinicians ICD-10.  I implored folks in both communities to think past the veneer of the federal regulations, read the preamble of the ONC Certification criteria (where we explained much of this) and think outside of the box.  Innovation?  Nope.  Folks have read only the veneer of federal regulations from both CMS and ONC, avoided creative thinking, and implemented solutions that check the regulatory box, blame the feds for it, and impose massive pain on a generation of clinicians.

It could have been avoided.  

Naysayers will insist .. "but what about the extra information that ICD-10 requires such as laterality?"  And my answer is that this information can and should be captured without ever exposing a clinician to an ICD-10 code.  Some organizations are already doing this.  Some EHR developers are already doing this.  If yours isn't, then you should ask them why not.  

The requirement is that ICD-10 be delivered.  There is no requirement that ICD-10 be entered into the computer (or paper) by the clinician.  When I order a diagnostic test such as imaging or blood work, those doing the testing will likely require ICD-10 so that they can pass it along to those who will pay them for the service (I say "may" because again - the requirements of them are to pass along ICD-10 to those who will pay.  But they have passed on this burden to the clinician without careful thought:  they, too could insulate the clinician from the burden and perform the translation from a clinical question ("why is this test being ordered?") to a billing transaction ("what is the ICD-10 code for which this test was ordered?")  Technology should capture the diagnosis in a terminology that I understand - MY language (HLI, IMO or SNOMED-CT) and if additional data is required - I should always be prompted for it - in the most elegant manner possible.  The information that I capture can/should then be stored in the patient's problem list if it's not already there (and of course if it IS already there - it should be offered as an initial selection to avoid replicating work that was already done!) and then translated in the background into the administrative code.  This should be opaque to the user.  Accessible?  Yes - sure.  Just as I can "view source" in my browser to see the HTML.  But really - who wants to do that?  Not me (most of the time).  Not you.  Nor will I need to see the ICD-10 code 99% of the time.

Don't burden your clinicians with ICD-10!  Avoid it.  Yes you can.  And you should.  Anything less is irresponsible.  Yes - some Who have been "educated" by high-priced consultants will ask for it.  But you shouldn't give them a faster horse.  Give them what they need.


Is it Disruptive?

It’s hard to hear a pitch, listen to a speech, or read blogs without hearing/seeing a claim that some cool new thing is distruptive. Most innovations are sustaining innovations. Here’s a good checklist for whether something is a disruptive innovation (via this post in HBR):

  • Does the product either target overserved customers (by offering lower performance at a lower price) or create a new market (by targeting customers who couldn’t use or afford the existing product)?
  • Does it create “asymmetric motivation,” meaning that while the disrupter is motivated to enter higher performance segments over time, existing players aren’t motivated to fight it?
  • Can it improve performance fast enough to keep pace with customers’ expectations while retaining its low cost structure?
  • Does it create new value networks, including sales channels?
  • Does it disrupt all incumbents, or can an existing player exploit the opportunity?
  • Does it disrupt all incumbents, or can an existing player exploit the opportunity?

3rd Platform for Health IT

For the low-low price of $4500 (that's $500 per page) you can buy this 9 page report on how the athenahealth-BIDMC alignment is evidence that cloud-based information technology will form the basis of tomorrow's health IT solutions.  Obviously, I've not read the report.  It's not clear if Bernie Monegan has either, but she's written an article about it, which has generated some buzz on the Internet in recent days.  (One wonders about a relationship between HIMSS - which owns Healthcare IT News - and ICD - but I don't recall that there is one) .. 

Let me save you $4500.  

Where the data lives doesn't make this new.   SMS (which became Siemens and of course is now Cerner) hosted hospitals' data in their data center in Malvern 25 years ago.  Call that a "cloud" in 2015 parlance, but a hosting facility is a hosting facility.  

Yes - there are some differences.  Traditional hosting is single-tenant.  The server(s) are dedicated to a given facility, and they're mirrored to a redundant facility for disaster preparedness.  The server looks, acts and feels like is in the hospital basement rather than in some data center in a secret mountain in Colorado - and there is a (virtual) dedicated wire that goes from the hospital to the data center.  The CIO can tour the data center and the guy with a pocket protector can point to "your" servers - and there they are - lights blinking away, fans whirring.  

And "cloud" these days invokes a multi-tenant model.  One big data bucket, and one big application layer, with a technical architecture that separates patients and providers in a way that privacy and security are managed well, but that eliminates redundant hardware and software.  The data and the software services are distributed logically and often physically.  There isn't one server where "your" data lives.  It's everywhere - inherently redundant.  athenahealth and PracticeFusion are obvious models of this in the ambulatory domain, while RazorInsights and iCare are examples of acute care products like this. 

This isn't the interesting part of "3rd platform" for health IT.  Yes - it's self-evident that distributed computing, mobile endpoints, and "loosely coupled" services will be part of the future health IT infrastructure.  Ho-hum.  The rest of the world has been there already for a half-decade.  Hosting your own Microsoft Exchange server in 2016 will be akin to driving a Chevy Nova.  Health care will catch up.  Slowly.  We'll see initial progress in the value based primary care settings:  Iora Health, Chen Med, Oak Street Health, and Qliance are already adopting entirely new care models - with entirely novel health IT platforms to support these models. 

After value based primary care, we'll see innovation in the LTPAC space. They are relative non-consumers of health IT, and therefore represent a unique breeding ground for innovation and creative applications of technology.  

The unique feature here isn't that the tools will "live in the cloud."  What's unique is that the tools will be centered around the goals of the individual rather than the goals of the care delivery organization.

We chose careers in health care because we wanted to have impact.  To help.  To make the world a better place.  Atul Gawande’s wonderful book, Being Mortal, reminds us that the profession of medicine has failed miserably at doing what is in fact most important:  understanding the goals of individuals, and helping us navigate that path. Together.  The book isn’t about death.  I had actually avoided it initially - worried that it was.  It’s about our pervasive and persistent inability to do what’s right in health care, and tells a handful of stories about some amazing people who are breaking with tradition and doing what’s right - with impressive results.

As I read the book - I pressed “replay” on vignettes from my career as a family physician, a parent, a software developer, a federal servant, and a son.   I ask myself how I fared in this context.  When I supported a patient’s decision to decline a medication that I thought would help them feel better, was I helping or hurting?  If I “took a strong position” on immunizing children, was I alienating parents from the care delivery system altogether, or “holding firm” on a “scientific fact?”  When I helped to create regulations that explicitly expressed certification requirements for health IT systems, was I protecting the public interest, or stifling innovation?  The answers, of course, are foggy.  What was the “right” answer for one individual may be different from what is right for another.  What's "essential guidance" for one software company may be "prescriptive regulation" to another.  One size does not fit all.

What's the 3rd platform?  It's the individual.  Designing our systems (not just our IT systems) in a way that helps us discover the priorities of each individual, and then adapt to support them. Driverless cars?  Of course.  Just tell me where you want to go.  Technology is an essential component of the solution.  But humans define where we are going.

The High Cost of Free Checkups | The Health Care Blog

Vik and Al's post on THCB was e-mailed to me this AM with a request for a comment.  My reply:

I completely agree.  And I completely disagree.  
I agree with Zeke (and the research he cites) that the "physical exam" is useless.  Indeed, when I was a full-time family physician, I would refuse to discuss/schedule an "annual physical."
But Al and Vik have conflated the "annual physical" with a proactive interaction between a care provider and an individual.  Notice that I didn't say "physician" (it need not be a physician) and notice that I didn't say "patient" as we need not think of ourselves - all of us - as flawed or "in need of care" in some way.  We're individuals and not patients.
But planning our health, just as planning our finances, or planning our home/car/helicopter maintenance schedules sometimes requires the assistance of a person who has more training or expertise than the individual.  
Appropriately managed, this is a regular event, which adds value as the foundation of a trusting collaborative relationship between an individual and a member of a care delivery team.  
Just as we needn't gather evidence that parachutes save the lives of humans who fall out of airplanes, we needn't gather evidence that this relationship is important.  Yes - text messages, e-mails, activity trackers, wifi scales and video chats are all appropriate adjuncts for the (ideally rare) face-to-face interaction.  But they're adjuncts.  Not substitutes.  We do need time together because we're humans.  A physical exam?  No.  of course not.  A "check-in" every year or three?  Absolutely.

It's time to stop calling them EHRs

It’s time to stop calling them EHRs.  Yes - we also need to stop calling them EMRs.  In 2011, ONC discussed the difference between the two terms, but I think that conversation missed the point:  whethere it’s “medical” or “health” that is the focus, these aren’t (shouldn’t be) RECORD systems at all.  We need to expand our expectations from CRUD to something that we really need: smart tools that help us collaborate toward improving health for individuals.   In November, when I floated this concept, I was teased (corrected?) for focusing on terminology and missing the point that we need EHRs to do more than just store data.

But it’s more than just terminology.  Our words mean a lot. A “record” system is for storage of records.  It saves information.  Our expectations will always focus on storing and retrieving information.  That’s the core of the design.  But in other industries - we’ve seen migration from information store/retrieve to intelligent platforms that anticipate our needs.  Does storage occur?  of course it does.  But storage of information is the byproduct of collaboration and not the goal.  

Let’s call it health IT - or even better - "IT for health.”  

Patient Centered IT

In my spam

This appeared in my e-mail today.  It’s an ad for some article that was supposed to prompt us to think about IT from a different perspective.  Should IT be delivered from a clinician-centric approach? How is that new?  I suppose it’s better than a “CFO-centered approach,”  but we deserve even better.  As an industry, we've lost focus on our priorities.  The needs of the individual are getting lost in a maze of fee-for-service motivated check-boxes and auto-generated drivel.  What's the foundation of IT that's best for a patient?  THAT’s what should be delivered.

AMA's letter to ONC

The AMA and 33 other organizations sent a letter to National Coordinator Karen DeSalvo last week.  The letter has seven requests of ONC:


  1. Decouple EHR certification from the Meaningful Use program;
  2. Re-consider alternative software testing methods;
  3. Establish greater transparency and uniformity on UCD testing and process results;
  4. Incorporate exception handling into EHR certification;
  5. Develop C-CDA guidance and tests to support exchange;
  6. Seek further stakeholder feedback; and
  7. Increase education on EHR implementation.


Let’s take them one-by-one … 


Decoupling EHR certification from the EHR incentive programs.  One could argue that this is already happening, and we can expect it to continue to happen.  Check.


Re-consider alternative software testing methods.  I’m not sure that “re-consider” is what’s in order here.  The letter asks ONC to re-consider the stance on scenario based testing.  But ONC’s stance is (and always has been) that scenario based testing is a great idea.  Is the goal of the letter to express enthusiasm for this model?  ONC will share the enthusiasm.  The harder part will be to create a framework that builds and maintains scenario-based test procedures.  This is a shared responsibility.  Shared by government (ONC and NIST) and industry (health IT developers) and - yes - the AMA and the 33 other organizations who sent the letter.  ONC has invited everyone to participate (here’s the open test development site).  So far - I don’t see much (any?)  engagement from the AMA or the others who signed the letter.  It’s relatively easy to write a letter saying someone else is responsible for solving problems.  Time to step up to the plate and participate in the solutions, folks!

Establish greater transparency on UCD testing.  Yep.  I agree.  ACBs need to enforce this, and ONC needs to get serious with those who don’t comply. UCD testing results not posted on the CHPL?  Give them 60 days warning (more than enough!) and de-list the product.  

Incorporate exception handling & C-CDA guidance and tests.  These requests expresses AMA’s ambition for ONC (and NIST?) to do full interoperability testing.  But as defined by congress in ONC’s authority - the certification program does conformance testing.  That means the products conform to the standards.  It doesn’t mean they have been tested with full end-to-end interoperability tests.  If we want ONC and NIST to do that - there will need to be an expansion of ONC’s authority and budget.  Asking ONC to do this is barking up the wrong tree.  AMA should lobby Congress on this one, not ONC. Yes - there is some low-hanging fruit here with the C-CDA. ONC could offer more explicit guidance to limit some of the optionality that exists in the HL7 standards.  I agree on this point.

Seek stakeholder feedback.  I think they do a pretty good job with this.  ONC’s FACAs are open to the public, transcribed, and always invite public comments.  

Increase EHR implementation eductaion. Well, ARRA funds are depleted.  While I agree that there is work to continue here - but ONC and the RECs and the developer community - I’m not sure that this can be increased in context of the current fiscal situation.  


I’ll enable comments on this post - as I’m interested in how others view this letter.

Writer's Block ..

Or maybe I should call it "Reider's block?" ..

Despite 15 years of blogging - this time, I've written and re-written a post so many times I can't count them.  So here's one to get me started.   

I had dinner last night with a former colleague who has had a long track record of success in government, health care, and education.  He’s getting close to retirement, and we talked about what has driven him – what he sees in himself as a leader, and why some people seem to find success so consistently, while others do not.

His goal after retirement is to teach in community colleges.  A community college grad himself – he reflected that these schools are special places that help others succeed.  Period.  The faculty are not arm-wrestling for status or grandeur. Students often have had other careers, or had less-than-stellar high school performance.  

He is a noble guy – with altruistic goals – and I think that this demeanor is what’s helped him succeed throughout is career.  I observed that his interest in teaching community college students aligns perfectly with how he’s approached every other job:  to help others succeed.  It’s not about himself or his own personal achievements.

This demeanor is uncommon.  But it’s certainly aligned with how I’ve tried to be throughout my career as well.  Success as a physician wasn’t ever measured by my income, or the number of patients I saw in a day – it was measured by my patients' success.  I served them.  Period.  To help them reach their own personal goals of health and happiness.

And then – at some point fairly late in my career – I realized that this approach – helping others succeed without judgment – without invoking MY agenda - was the same set of attributes that would align with success in other domains.

Fast forward to January 2015.  My dad has been in the hospital and I’ve once again witnessed the dysfunction of our care delivery system from the other side of the stethoscope.  It’s a sobering reminder.  The culture of health care that I witnessed in Boston (at the “best “ hospital in the world)  remains disconnected, distracted, and aligned on the wrong incentives:  

  • Revenue.  Fee-for-service models push care providers to maximize charges rather than care quality, patient experience, or best outcomes.
  • Recognition.  Smart, assertive heroes who do more, and write more papers and get more national or international recognition are perceived to be "better" physicians than folks who listen, share decisions with patients, and really focus on the right stuff.

Despite many efforts to change the way we pay for care, educate our physicians, or create stage 4 cultures - so far, it's not working.

But we can't stop trying.

And so my next chapter will be focused on a few guiding principles:

  • Work with great people who want to do what's best for others - to really add value to the world in a way that will empower others to find health and happiness.
  • Facilitate new cultural norms in health care that focus on shared decisions, collaboration, transparency, and compassion.
  • Avoid people and organizations who want to be "rock stars" and succeed for the sake of success - either in status or revenue or power.

We're ALL on the same team

image from http://s3.amazonaws.com/hires.aviary.com/k/mr6i2hifk4wxt1dp/14102517/441b3bd8-3e95-4fe5-9437-735ff2c21446.png

Have you ever noticed that when baseball players hit a single and land on 1st base, they can be seen chatting with their "enemy" on the bases?

I enjoy watching them - and wonder what they're talking about.  It reminds me that despite the animosity often expressed by fans, baseball is just a game.    The players are all players.  They may switch sides sometimes, but they are really all the same - working toward the same goals, with the same methods.

Players in every industry change teams.  It's normal, common and in fact it's a good thing.   When we leave one "team," we bring the culture, values, passion and insight that we built into another organization.  Such diversity of thought, values, vision and culture is what keeps us all growing as people and as teams - working toward shared success.

This isn't always apparent to those off the field. A few years ago - a good friend of mine was diagnosed with a serious illness.  Some of the greatest support for her (and her family) was provided by her counterparts at competing companies.  It was touching - but not surprising - to see others rally around her and support her as she fought back to complete recovery.  

And what a privilege it has been for me to work within a community of government leaders, industry leaders, community leaders, consumer advocates, informaticists, and researchers as we strive toward better health for all.  

I started this blog fifteen years ago on November 15th.  Here's the first post.  Stay tuned for (much) more from me in the next few weeks - toward a 15 year anniversary post on 11/15/14, and a re-launch of Docnotes for its 15th year.  


It's not about the technology

I got a call from a friend last night.    He's the CMIO for a large hospital.  He's smart, works 80 hour weeks, and he's passionate about getting his EHRs to work right, the providers trained right, the order sets configured right, and (most importantly) the patients treated right.

He's been in the role for a number of years - and he's good at his job.  Very good at his job.  He knows the systems (from two EHR vendors - an inpatient system from company A and an ambulatory system from company B) better than many employees of the companies.    He's memorized the criteria for Meaningful Use down to the section and subsection numbers.  It's amazing.  I had a similar role once - about ten years ago - and I vividly recall mentoring him into his new position back then - thinking that his hospital would do so much better than mine - as he'd see the puddles we had already stepped in.  .. 

He's an incredibly gifted physician too - and continues to see patients at least 20 hrs a week - with a full call schedule.  

But tonight he called me because he wants to quit his IT job and go back to being "just a doctor."

Because the politics of the IT world have been too much for him.

"The analysts didn't finish the order sets and blamed the doctors for not reviewing them."

"And the doctors insist that they WANT to review them, but the analysts tell them that they're not ready to be reviewed!"

"We're behind schedule and all they do is blame someone else."

"Why are they lying?  Why do they get mad at me when I point out what's going on?" 

I listened.  And listened.  It sounds dreadfully challenging.  He's implementing TWO EHRs, and getting CPOE up and running in an outlying hospital, and migrating a community of physicians to new workflows, new processes and new habits.  This is no simple task - and he's got the technical details down cold.  

And he's done a great job with all of it ...

Except his relationship with the IT team.    

This is not uncommon.  But there is a solution.  An easy one, in fact.  

"Your should pretend you're a doctor."  I said.

    "I am a doctor!"

"You're a doctor when you are with your patients. But it doesn't sound like you're a doctor when you're with the IT team.  It sounds like you are an angry parent!"

We talked about this for a while.  He wasn't sure where I was going - but he was intrigued.  He knew that somehow I have found it less difficult to navigate the political mine fields of hospitals, academia, industry and government.  Indeed - his minefield is my Fenway Park!  Am I serious that I want him to treat the IT team like they are his patients?


"If your patient tells you that they have been dieting and exercising but they are still gaining weight - what do you say?" 

    "I would say that I believe them 100% - that they are dieting and exercising and that I want to find ways to help them."

"Do you really think they have been dieting and exercising as much as they say?"

    "No.  Of course not."

"So why do you not challenge them?  Why don't you point out how wrong they are - and that they are fibbing?"

    "Because it's not important if I am right.  That won't help them."

"So why is it important that you are right that the analyst streched reality a bit about doing the order sets for Dr PooBah?"

    "Because they didn't do what they are supposed to do.  I need to point that out."


    "OK - I can see what you are saying but it still doesn't make sense.  How will my NOT judging them make them get their work done?"


So this is the key leap of faith for him.  It seems like these are different settings, different goals, and he should use different skills.

But it's not necessary.  The same skills that make a great empathic physician will also make a great empathic results-oriented CMIO.

He's built a (medical) career of great habits that we can leverage.  The habits he'd built are the ones he uses every day to care for his patients in a collaborative, meaningful, non-judgemental way.

The key to his success in the IT world is to say (to himself) just what he says to his patients:

  "Because it's not important if I am right.  That won't help them."

The focus shifts from blaming them for being lazy, lying IT enemies - to "folks who need my support."

Dr CMIO - you already know how to do this!

I could tell he was interested - but still wasn't quite at the point where he could make the leap.  We talked about the dysfunctional team of IT analysts, how they gossip and argue and sidestep work.

"It sounds like they are very unhappy"  I say.

He got quiet.

"Yes - they are - and they make everyone else unhappy."

"So what do you think would happen if they felt like you were an ally?  Like you wanted them to be successful?"

We went on like this for an hour or so.  It's a hard shift - but quite powerful.  He remarked that I was soundling like a buddhist - and I pled guilty - but pointed out that this is not just a buddhist principle to avoid judgment - it's a core component of many of the "success in management" books too - most of which avoid invoking religeon or spirituality.    A few good ones to consider - probably required reading for any CMIO:

Energy Leadership

Five Dysfunctions of a Team

7 Habits of Highly Successful People

I'm giving a talk to a bunch of CMIOs in a few weeks.  Maybe I'll leverage this vignette into a little sermon powerpoint.