Demystifying healthcare transformation Part 2 – ICD9/10 #healthcare #ICD-9 #ICD-10 #BPM

This is Part 2 of a three-part series on The coming storm in healthcare.

The insurance industry, as it grew, developed standard codes to allow healthcare providers (such as doctors, clinics, hospitals) to bill for discreet services. There are 15,000 codes in the ICD-9 standard and it still isn’t enough.

10x

The new standardized codes, ICD-10, have ten times the number for a really good reason; there has been a shift to more outpatient, home and long term care. There are advances in medical technology and procedures that demand new classification. There is also a greater need to define non-acute conditions.

On the quality side, there needs to be greater reporting around healthcare outcomes, trends need to be tracked, quality analyzed, comparison of outcomes from different treatment methods and much more sharing internationally. The rest of the world is way ahead of us on this, leaving us unable to share research and co-manage global disease.

Looming deadline

It would be a big mistake to think this is a simple translation issue and has been described by an industry insider as a realization that, “This was a people issue, an awareness issue. This was a change in the way we did just about everything.” With a deadline of October 1st, 2013, it represents a significant revenue risk to healthcare organizations and patients.

Think of healthcare payers and providers as ‘trading partners’ that conduct transactions that affect revenue for each…revenue keeps the doors open and the lights on.

Lest we forget, there’s also a risk to patients who might be charged incorrectly or have services wrongly denied. For the industry, patient billing issues cause expensive manual intervention, low patient satisfaction and drive up the cost of doing business.

Coordination

To successfully reach the end of ICD-9 intact, those trading partners will need to coordinate change in unprecedented ways. If you consider the need to be ready well before the deadline, there is only the next year for significant cooperation to take place.

That level of coordination will require news ways of doing business…outside-in thinking. It won’t be solved by implementing a single software system but by using automation to make cooperation easier across multiple parties and systems. There’s an enormous opportunity for the application of social technology.

Long haul

This doesn’t all go away on October 1st. Maintenance to the code standards will make this an ongoing change management exercise that will push IT systems and the people that perform the work of healthcare. By 2015, CORE Operating Rules need to be in place. When an individual walks into an ER or Hospital, the facility must have point-of-service knowledge of eligibility, out of pocket costs, and what’s covered.

Once in the facility, accurate and timely data must be available to ensure the best patient outcome. That data should be predictive and on-demand. Outside of acute care, data must be equally available as a predictive and preventative tool. With most data trapped in silo’d applications, that’s a tall order. There’s never been a stronger need for a transformation platform that enables ongoing change in process and technology.

With many healthcare organizations struggling with getting EMRs in place and the change from 4010 to 5010 standards for transmitting claims, it will be an interesting year.

Up next: CORE and healing healthcare