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Paying the high price for ICD-10 compliance when using EMR systems in US hospitals

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Lucky for us in Malaysia, our hospitals with EMR systems with technology already incorporating the ICD-10 code set, are not up against paying the high price of implementing ICD-10 unlike in the US where hospitals using EMR/EHR systems are gearing up for the October 2013 ICD-10 dateline (which is likely to be delayed again to October 2014).

One example of an US hospital system that encompasses 14 hospitals, is the North Shore Long Island Jewish Health System, N.Y. They estimate the price tag will be about US$50 million (about RM158 million) including project management, I.T. remediation(some 90 applications), training and other areas.

Sutter Health which runs 24 hospitals across northern California, is another example which provided an even higher price tag–well over $100 million (about RM316 million), including $60 million (about RM190 million) for technology remediation (some 146 applications will need to be remediated) and $25 million (about RM79 million) for a computer-assisted coding program

Both these organizations are said to well ahead of the rest of the industry in their ICD-10 planning in the US. However, they are being cautious and concerned with  long-term financial impact on their revenue when converting past billing claims to ICD-10 and also estimating where documentation would need to be enhanced to support the more granular codes in ICD-10.

In the US, ICD-9 codes have been used mainly for billing, historically. It seems every clinical encounter that gets billed to an insurance payor includes diagnosis designations, encoded as ICD-9 codes.

Thus, I can understand the profound impact of paying the high price of implementing ICD-10 in the US when changing the fundamental method of encoding diagnoses to a whole new system .

The rationale for making such a change (given the disruption that will occur) is that the ICD-10 code set is more detailed and extensible, allowing for more than 155,000 different codes, and permits the tracking of many new diagnoses and procedures (a significant expansion on the 17,000 codes available in ICD-9).

As we know ICD-10 was developed by the WHO and released in 1992, soon after the ICD-10 system was adopted relatively swiftly in most of the world including in Malaysia.

Abridged, from the article The High Price of ICD-10 by Gary Baldwin, June 26, 2012, Health Data Management reporting  from the HFMA conference June 24-27 2012 in Las Vegas, where panelists shared the above estimates.

With additional references from:
practicefusion.com/, Website
ehrscope.com, Blog
pdmanesthesia.com/, Blog for the image in this post

The Five Rights of Data Administration!

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If you read the post Documentation of medication administration in medical records, I am sure you did not miss reading about how clinicians and nurses use the “Five Rights of Medication Administration” to ensure proper patient care.

If you work in an EMR environment, then the following infographic, entitled “The Five Rights of Data Administration,” created by Symantec to help Health IT staff and users like you, Health Information Management(HIM) / Medical Records (MR) practitioners answer important questions about the use, access, and availability of critical patient data. This infographic outlines specific best practices to ensure that patient information is kept secure regardless of where it is. The infograhic also helps you and Health IT staff in organizations like the hospital you work in better understand the administration of patient data

I believe HIM/MR practitioners working in an EMR setting need to adopt similar but modified best practices for ensuring proper security and privacy for patient data based on the specific best practices outlined in this infograhic.

Note: Click on the infograhic above to view a larger image in a new tab of your current window.

From this infograhic, you need to cultivate the following specific best practices with coordination, guidance and help from IT staff of your hospital.

  1. Right Time – data in EMRs should be available to authorised personnel in your department whenever they need it and must be backed up and secure
  2. Right Route – users like clinicians who need access to EMR data regardless of where they and the device they’re using, must have ready access to updated data your are responsible for at your end
  3. Right Person – ensure only the right people have access to certain information though access verification in your department
  4. Right Data – prevent unauthorised tempering or accidental corruption of data with only users entitled or authorised to have access to data in your department and minimising or banning Bring Your Own Device (BYOD) mobile devices
  5. Right Use – ensure only the “minimum necessary” information is provided to external sources who request data that can be extracted from your end of the EMR system, thus assuring confidentiality

Just like medication administration is taken very seriously with the utmost accuracy and attention to detail as they can mean the difference between life and death, the proper administration of patient data should also be taken very seriously as it too can prevent misdiagnoses or mistreatment without accuracy and attention to detail.

Documentation of medication administration in medical records

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Joint Commission International defines medication (JCI 2010) as ‘any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; over-the-counter drugs; vaccines; or diagnostic and contrast agents used on or administered to persons to diagnose, to treat, or to prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; and intravenous solutions (plain, with electrolytes and/or drugs.’

Preparation for medication administration in a hospital begins with the order for medication, in most circumstances written by a doctor. A record of orders for medication (medications prescribed or ordered), the dosage and times the medication and other treatments was administered is kept in the medical chart of each patient.

Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (medications administered “as needed”) order. Standing orders (also referred to as scheduled orders) are administered routinely as specified until the order is canceled by another order.

Before administration and to ensure safe administration, medication records are strictly on hand at time of administration and medication given according  the “five rights” namely:

  1. Right patient
  2. Right drug
  3. Right route
  4. Right dose
  5. Right time

Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document.

Hospitals usually have policies and procedures regarding documentation of medication administration. Such policies and proceudres would entail that a listing of all current medications taken prior to admission must be recorded in the patient’s medical record and is available to the pharmacy, nurses, and doctors. An established process contained in such medication related procedures may include that this listing of ‘all current medications taken prior to admission’ is readily available so that it can be used to compare with ‘initial medication orders’.

Now, just in case your hospital is been prepared for JCI accreditation, the medical records you keep must comply with two JCI standards to meet its requirements for proper documentation of medication administration.

The first of the two standards mentioned above which your hospital needs to comply with is JCI Standard MMU.4, which states that ‘Prescribing, ordering, and transcribing are guided by policies and procedures.’

Medical, nursing, pharmacy, and administrative staff in your hospital actively collaborate to develop and monitor such policies and procedures.This standard guides the safe prescribing, ordering, and transcribing of medications.

What concerns you as the Health Information Management/Medical Records practitioner directly is the process of transcribing of medications (by doctors, usually the clerking doctor at admission), which includes ‘a listing of all current medications taken prior to admission’ that must be duly recorded in a patient’s medical record, which will then be measurable for complaince by JCI Standard MMU.4, ME 5.

However, do take note your hospital must comply with JCI Standard MMU.4, ME 6 which requires that this listing is important to be maintained in a medical record since it is used to make a comparison between ‘all current medications taken prior to admission’ against ‘initial medication orders’.

The other direct concerns to you when your hospital is been prepared for JCI accreditation is to be beware that your medical records must contain medication documentation as required by JCI Standard MMU.4.3 which states ‘Medications prescribed and administered are written in the patient’s record’ and that this documentation in your medical records have evidence that can show:

  • medications prescribed or ordered are recorded for each patient that is measurable by JCI Standard MMU.4.3, ME 1
  • medication administration is recorded for each dose, measurable by JCI Standard MMU.4.3, ME 2
  • medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer, measurable by JCI Standard MMU.4.3, ME 3

In summary, in case your hospital is been prepared for JCI accreditation, then look out for JCI Standard MMU.4 and its two requirements ME 5 and ME 6, and also JCI Standard MMU.4.3 and its three requirements namely ME 1, ME 2 and ME 3, so that the medical records you keep complys with these two JCI standards and so to meet its five respective requirements for proper documentation of medication administration.

References:
Carol, T, Carol, L & Priscilla, L 1997, Fundamentals of Nursing: The Art of Science of Nursing, 3rd edn, Philadelphia: Lippincott-Raven Publishers

Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Janet, W & Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Patricia, AP & Anne, GP 1997, Fundamentals of Nursing: Concepts, Process, and Practice, 4th edn, St Louis, USA, Mosby-Year Book, Inc.

Work Not Documented Is Work Not Done

INFOGRAPHIC: Format Of ICD-10 Diagnosis Code

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The ICD-10 Code Structure accommodates for the expanded number of characters in diagnosis codes which allows a greater specificity to identify disease etiology, anatomic site, and severity as can be seen from the diagram below.

The following infographic is an example of the ICD 10 code for S52.521A, which is self-explanatory and shows the more detailed information gained through the added characters.

The example of the forearm fracture above demonstrates the use of the full code titles, unlike that used for the ICD-9 diagnosis code set.

Pain assessment findings documentation in medical records

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I think as Health Information Management(HIM)/Medical Records(MR) practioners, it is never objectionable to know the background on pain assessment documentation found among the contents of a medical record.

A background I would consider knowing about is what is pain all about, how pain is managed including the assessment process, the tools used to measure pain, and pain assessment documentation.

Pain which is now considered to be the fifth vital sign, is also assessed whenever the other four vital signs namely temperature, pulse, respiration, and blood pressure are measured.  Patients are asked on a regular basis if they are experiencing pain. The evaluation of pain, along with other vital signs, alerts the nurse and other healthcare providers to the necessity of addressing the patient’s pain. Relief of pain helps the patient to be more comfortable and to recover more quickly.

What is pain then?

Because pain is a subjective symptom which only a patient can describe it, pain is difficult to define. However we know as humans that pain is the body’s signal of distress, and is very difficult to ignore. Most of us try many remedies to relieve pain, often without success. Ultimately, it is one of the most common reasons that most of us seek healthcare.

Here I list some notable definitions of pain, a universal human experience:

  • ‘Pain is whatever the experiencing person says it is, existing whenever he says it does’, stated by pain theorist, Margo McCaffery
  • The Agency for Healthcare Research and Quality (AHRQ) in its clinical practice guidelines for acute pain management states that the ‘client’s self-report is the single best indicator of pain’
  • One definition of pain in a medical dictionary includes ‘a feeling of distress, suffering, or agony, caused by stimulation of specialized nerve endings’
  • The International Association for the Study of Pain defines pain as ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage’

Pain is classified in several ways. Duration and etiology are often classified together to differentiate acute pain, chronic nonmalignant pain, and cancer pain. Pain location classifications include cutaneous pain, visceral pain, and deep somatic pain, radiating, and referred. Phantom pain can be perceived in nerves left by a missing, amputated, or paralyzed body part. Other types of pain are neuropathic pain and intractable pain.

I am sure you would have noticed these terms used in the medical record in the course of reading the medical record, example for ICD-10 coding purposes.

The experience of pain is quite complex and the multidimensional complexity of pain can be described in seven dimensions: physical, sensory, behavioural, sociocultural, cognitive, affective, and spiritual.

Pain is managed with the use of pharmacological (oral medication, Intravenous Medication (IM), Intravenous Venous (IV) medication, IV continuous medication) and non- pharmacological interventions (which may include warm and cold compresses, heat and cold applications at a Rehabilitation Department, position change and relaxation exercises to control the patient identified pain). Pharmacological and non-pharmacological interventions extend beyond pain relief, encompassing the patient’s quality of life, and ability to function or work productively. Pain relief after surgery is improved with the combined use of different classes of analgesic. There may also be an associated reduction of the dose of each analgesic drug and the intensity of any side effects.

Patients are assessed appropriate to patient’s age:

  • within one hour on admission to the ward, including Day Surgery and Endoscopy
  • upon inter-ward transfer
  • at the beginning of each outpatient visit to the departments such as the AE, Rehabilitation Department, Oncology Centre
  • following a surgical procedure or treatment
  • when the patient complains of pain
  • before and after administration of medication and / or treatment.
  • at time of discharge

Allow me now to go on and discuss the pain assessment tools and findings documentation found in medical records.

Pain screening is very important in developing a comprehensive plan of care for the client. Therefore, it is essential to assess for pain at the initial assessment. Pain intensity measurement tools such as a 1 to 10 Likert scale may be used.

There are many pain assessment scales; for example, Visual Analog Scale (VAS), Numeric Pain Intensity Scale (NPI), Simple Descriptive Pain Intensity Scale, Graphic Rating Scale, Verbal Rating Scale, and Faces Pain Scales (FPS, FPS-R), and the more common Wong-Baker Faces Pain Scale (a picture scale).  You can find out more on some of these scales from http://www.partnersagainstpain.com/measuring-pain/assessment-tool.aspx (this link will open in a new tab of your current window).

While there are no laws in Malaysia that  necessitates pain assessment and documentation, some states in the United States have passed laws necessitating the adoption of an assessment tool and documenting pain assessment in patient charts along with temperature, pulse, heart rate, and blood pressure.

So what is important for you as a HIM/MR practitioner is that pain assessment findings and treatment are documented in the patient’s record and readily available to those responsible for the patient’s care.

However if you working in a hospital in the process of accreditation,  for example using the Joint Commission International(JCI) quality standards , then it is important to know the JCI requirements to improve the management of pain which are as follows:

  • patients have the right to appropriate assessment and management of pain
  • on-going pain assessment should include the nature and intensity of pain, thus the use of pain scales to help clients determine their level of pain
  • responses to evaluation of pain should be recorded in a manner that promotes regular reassessment and follow-up
  • staff must be oriented and competent in assessment and management of pain
  • policies and procedures supporting ordering of pain medications must be in place
  • patients and families require education about effective pain management.
  • discharge planning should address the patient’s needs for management of pain

The JCI requirement that specifically requires that the medical record contain documentation on pain assessment is non-other than the JCI Standard AOP.1.7 which states that ‘All inpatients and outpatients are screened for pain and assessed when pain is present.’

The intent of JCI Standard AOP.1.7 is to ensure that a screening procedure is used to identify patients with pain during the initial assessment and during any reassessments. When pain is identified and when the patient is treated in the hospital, then this assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs. JCI Standard AOP.1.7 Measurable Element (ME) 3 then measures if the medical records have evidence that ‘the assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the hospital and the patient’s needs.’

References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Janet, W &Jane, HK 2010, Health assessment in nursing, 4th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia PA, USA

Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th Edition, USA, JCI

PartnersAgainstPain.com website