The switch from ICD-9 (17,000 codes) to ICD-10 (141,000 codes) will have a huge impact on physician practices.  Use this online translator to see how your most commonly used codes will make out in this transition. 

Types of changes you will see:

Approximate Match: Diagnosis has a direct 1-1 mapping, but the diagnosis text has changed slightly (about 49% of new codes)
Exact Match: Diagnosis has a direct 1-1 mapping and the diagnosis text remains the same (about 24% of new codes)
Match with Multiple Choices: Diagnosis maps to a set of diagnoses, from which one should be chosen (about 19% of new codes)
No Mapping: Diagnosis does not exist in the ICD-10 code set (about 3% of new codes)
Complex Mapping: Diagnosis matches to multiple sets of ICD-10 diagnoses (about 3% of new codes)
1 to Many: 1 Diagnosis code maps to 2 or more ICD-10 codes (about 2% of new codes)

Now that the Supreme Court has agreed to rule on the Affordable Care Act, all industry observers will be waiting on that outcome.  There will be much prognostication about will they or won't they and what happens if they do or if they don't.  This will truly have landmark impacts.

As you prepare to settle in to your virtual recliner for a season of court watching (and shouldn't we have some of those ESPN guys provide the play-by-play analysis, replete with cool graphics, instant replay, and endless factoids about Justice Roberts scrolling at the bottom of the screen?), this NY Times article provides a good summary of the changes likely to come and remain, regardless of how the Gang of Nine votes.  It is a good read.

'To stop procrastinating' is a common New Year's resolution.

According to the folks at KLAS, the HIT research firm, it would be good if a lot of providers adopted that resolution now as it relates to ICD-10.  Very few provider organizations are anywhere close to being on track for the October 13 date.  Some are overwhelmed with Meaningful Use and 1,000 other issues.  Some are in denial that this could really be that big a deal.

But so far, the Feds have shown no sign of backing off and since this affects whether a claim can get out the door, much less paid, not being ready is a big gamble.

Click here for a related story.

Well, let's get this party started...

Supreme Court agrees to hear ObamaCare case.

Here is a story, granted from our backyard up in Boulder, that lays out some of the pricing and economic specifics around public HIEs.  The texture of the story has a little more depth to us because we know some of the players and some of the dynamics in that market.  While there are local market peculiarities in this story, there are some general issues that can be extended to a lot of markets.  Here are a couple:

• Federal grants to build a public HIE are one thing, but most likely, revenue to support on-going operating costs have to come from players in that market.  Until that problem is solved, the question of HIE sustainability remains open.
• $85 per provider a month, the price being asked by the Colorado RIO, is getting a lot of push back from physicians.  Bigger groups with leverage are pushing to negotiate side deals.  Smaller practices without clout are not jumping in.  Time will tell, but that dog (at that price) may not hunt.
• Related to that, when a primary care physician has to pay $1,020 per year to pay, but the largest system in the state (13 hospitals) pays only $300,000 for the year, expect many physicians to cry foul.
• Many of the docs in the community are already connected to their hospital and one another through the private HIE that is part of the common EHR system they all chose (and, surprise, this is one of the reasons they chose a common system).  Private HIEs, with a far more obvious value proposition to those involved in that particular delivery network, will continue to erode participation in public HIEs.
• The argument that docs should pay up because this is the right thing to do and will lower overall costs is either naive or down right patronizing.  The paying physicians do not participate in those savings, but they accrue to the payers (patients, employers, government, payers). Telling physicians that they should take a $1,020 a year pay cut for that motive is not a winning marketing strategy.

A new study indicates that physicians need at least 3-5 days of initial training on their EHR if they are to be able to use it adequately.  The study also noted that half of the respondents got three or fewer days of training.

Regular readers know this is a constant point we make in this space, even as we acknowledge we have a dog in the hunt since we are EHR implementers.  However, this is highly complex software, not an app downloaded to a smart phone while standing in line at the grocery store.  The full range of a physician's work domain, something that takes years to teach, is reduced to an EHR program.  Assuming someone, even someone smart enough to get into and out of medical school, can master that without significant training is just silly.

Or conflicted selling by the software vendors.

The vendors are clearly at the front of the parade.  They have the brand equity and the feet on the street to frame the conversation.  But too often, the landrush mentality for the coveted installed base means that the cost of implementation and training gets shaved or shelved all together.  Some of the largest vendors are getting hammered now by the market as these chickens come home to roost.

If you are a buyer of this technology, tell yourself the truth, even if your sales person will not. There is a lot of work to implement this much technology.  Database configuration, user set up, data conversion, and interfaces are some of the technical components.  Clinical consulting to change your work flow to leverage the technology is another key element that is worth the investment.  A lot of project management is required to keep all the pieces in line with one another.  But at the heart of it all is the training of the people who will use the system.  Short this at your own peril.

A new study reports that only 12% of the Health Information Exchanges studied are financially self-sustaining.

Funny how many organizations launched first, hired people, bought technology, printed cool brochures and are only now getting around to addressing the business model question.  We've launched a few organizations and seem to recall the business model, specifically the revenue model, being one of the very first things you have to nail down.

It is ironic that even before HIEs are out of the ground and running that the E in the acronym, exchange, is already a commodity that no one wants to pay for. 

Remember in the late 90s when the Internet was just a pup and we all were going to pay dearly for content?  Then here comes YouTube, Wikipedia, and 5 million bloggers. Revenue streams really do matter.

At the bottom of the linked story is the hidden gem.  More and more of the HIEs, and a disproportional share of those that are sustainable, are not shared public utilities, but privately held exchanges where the exchange of information is not an end to itself, but a key enabler of a larger strategic vision.

While it is fun to say, 'Well if you live in Chicago and are vacationing in LA and end up in the ER, we should be able to click and find your allergies and meds,' that is not a winning business model. 

This is not about passing bytes.  It is about enabling networks of providers of care to come together to deliver that in different ways. Delivery organizations that have such a vision have no trouble sustaining the exchange.  It makes the vision happen.  Absent that, no one wants to pay...for obvious reasons.

On a related note, dust off your mountain west gold mining history.  A lot of dreamers went bust in the hills looking for the nuggets, while the guys at the depot selling pick axes did just fine, thank you.  The vendors selling the HIE tools are also grinning.

The final ACO rules were published by CMS last month. 

If you subscribe to any health news sources at all, your inbox has been full with analysis and commentary. We've been reading and digesting as well.

There are a lot of details, but the general take-away is that the highly negative reaction to the preliminary rules, with CMS pilloried from all quarters, resulted in a general weakening across the board.  Three sample points:

• There are no more penalties, just up side sharing on the savings.
• The quality measure got reduced.
• There is a pre-payment option for small hospitals that can't afford to invest up front.

If you are a cynical taxpayer, and who is not these days, you might scoff that just a weakened program really does not push hard enough to solve the big Medicare and Medicaid problems.

If you an organization that wants to play in the ACO space, the ante just got lower.  More health systems will now likely tip over and join the party.

If you are trying to read the tea leaves, you see CMS and the administration really, really, really believe ACOs are the way to solve this and are doing everything they can to plant and water seeds, even if the seeds will evolve at a slower pace than originally promised or hoped.

The news from this study that the larger the practice, the higher the EHR adoption rate is probably not news.  That is what most people would assume to be the case and what we've been seeing for a couple of years now.  But it is always good to have data, even if they confirm the obvious.  People in San Diego watch the weather in January, even though every day is the same.

Two reasons for this trend are obvious.

First, pricing realities simply work against small practices.  We've priced deals on multiple software platforms for practices of every size.  We priced them years ago when we had no clue as to what we were doing and we price them now with tons of implementations in our rearview mirror.  The results are always the same...total cost of ownership on a per physician basis is nearly impossible to justify for a solo provider, still breathtakingly steep for two docs, getting there for three, and then at four, the cost per physician curve flattens out to the point that four physicians is not that different from ten, on a per provider basis.

This is reality. Period.  Certain EHR vendors are attempting to dodge this reality, but they are doing so by simply punting the implementation work to the practice and severely limiting the configuration options necessary to really make the software work for the practice.

Two, as a rule bigger practices simply have better talent and leadership for the journey. Whether the talent is in-house or hired from the outside, they can get clinical consultants and project managers and better trainers and more to make it work.  They also generally have the right leadership for the change effort because they have had to address the leadership issue already.  The physician and administrative leadership that makes a big group work comes in handy when implementing such a transformative technology.

Making it as a small practice looks tougher and tougher.

We've been consistently skeptical of the CMS ACO program here in this space.  There are many reasons for our raised eyebrow, but none is more powerful than the consistent pushback from the ACO table by the big, mature integrated delivery systems that are tailor made for this program.  This story in Politico details the thinking of the Henry Ford system in Detroit, a member of the mature, integrated behemoth class for sure, to not participate in the CMS ACO program.

Two things are noteworthy for us in the story.

First, Ford is doing several things, including a massive medical home build out and participating in the CMS bundled payment program.  They are also doing some interesting things with the commercial payers in their market.  Here is an interesting quote from the story: “Health plans can do things that government programs aren’t able to do. Those models that exist in the private sector today are much more flexible [than CMS programs], tailored to the needs of providers and consumers.” 

And that is the point.  CMS rolling out one program that has to be applied in many diverse markets is not a good idea.  But when local health plans and local provider networks, hospitals and aligned physicians, sit down together to design what can work in their community, some good stuff will emerge.

We continue to believe in the ACO idea, but the commercial (read: local) version of it much more than the CMS (read: federal) version.

Second, in the endless discussions we've had over the last few years about the economy, one of the themes is 'uncertainty,' specifically the role uncertainty plays in the decision making of businesses.  As you read this story, you get a firsthand view of how uncertainty played in the actions that will, and will not, be taken by the Henry Ford system.

For the skeptics who wondered if the checks would ever flow (and we confess to asking that question ourselves early on), here is the latest update.

CMS paid out almost $90 million in September, bringing the total to date to about $870 million.  The agency says it is on track to pay over $1 billion by year end.

The quick math on the September numbers shows right at $18,000 per eligible provider (physician) and a bit over $2 million per hospital, right in line with expectations based on the legislation.

17,000 new providers registered for the program in September, bringing the total to about 114,000 providers.

Here is a story about whether metadata standards should be a part of the Stage Two requirements for Meaningful Use.

The quick headline on metadata is that this involves 'tagging' data so it can be referenced in multiple ways.  The idea will make the growing pile of healthcare data more valuable in the transformation of the industry.  It is a good thing.

But as the warning from the advisory group points out, this is a very complicated step that has to come way late in the process or we could have a mess on our hands.

A vision of the value of metadata is good and our continuing to press to that end is important.  But the road is long.  A lot of patience and hard work lies between here and there.

As we have said repeatedly, we believe in the power of HIT to help transform the industry.  We've seen it work in many other industries.  But while individual organizations can experience gain and improvement early, industry-wide transformation comes late, when enough pieces of the new infrastructure are in place to reach a tipping point.

Have a sandwich.  We're going to be here for a while. 

On a recent business trip, I had the chance to swing by my mother-in-law's with plans to take her to dinner.  No dummy am I, the value of such a move was obvious and evident. 

Instead, I ended up taking her to the emergency room with some heart issues.  Fortunately, she is OK and that was probably worth more than a nice dinner.

Twice, first in the ER, then later in the room with the consulting cardiologist, I saw young physicians whip out their iPhone to make a quick check on an unusual medication she was taking.  It was fast, easy, and as integrated into their workflow and thinking as the pager of old.  Both times, the information changed their thinking and the discussion about her diagnosis.

Thus, it was no surprise when a read the story that 80% of physicians are reported as using a smart phone or mobile device in their practice.  The math in the overview story is a little fuzzy, but the headline holds none the less.

This study, and my personal anecdote, suggest a couple of things.

Docs, especially younger ones, are not at all hesitant about integrating technology into their work. No surprise there.  This group is more comfortable thumbing a keyboard in the palm of their hand than sitting in a corner talking quietly to a dictation machine.

However, this usage was for a very specific, very focused task (looking up an unknown med).  The technology clearly beat the alternative (Hey, where the heck is the PDR?).  How this type of usage gives way to bigger footprint applications (the EHR) remains to be seen, but implementers would be wise to take this natural willingness to use these devices and build upon it.