When the first U.S. Ebola patient was admitted to a Dallas hospital in the summer of 2014, the ensuing media firestorm scrutinized nearly every aspect of the U.S. healthcare system’s readiness to deal with an epidemic that had already left thousands dead and dying overseas.
From isolation management and diagnosis protocols to safety procedures and even electronic health record (EHR) systems and utilization, it seemed that no stone was left unturned.
There was, however, one glaring oversight when identifying weaknesses in the U.S. healthcare system: the limitations of ICD-9.
While the rest of the world is leveraging the richness of detail inherent in ICD-10 to track and monitor patients with Ebola and other illnesses and diseases, U.S. providers cannot even code for Ebola because a diagnosis code for it does not exist in ICD-9. Instead it is bundled with “other specified diseases due to virus” or under “hemorrhagic fever not elsewhere classified.”
Frozen in Time
It is not just the rare viruses that are left out in ICD-9. The Centers for Medicare & Medicaid Services (CMS) posted the final updates to the code set in June 2012. Since then, it has remained frozen in time, with no updates made and no room to make them. Thus, even something as common as new strains of influenza that emerge annually cannot be properly coded under ICD-9.
H1N1 (swine flu) and H5N1 (avian flu) were the last two influenza types to be given separate ICD-9 codes, rather than the strains being added to the lumped-together influenza codes. This means that from a purely statistical standpoint, there is no way to differentiate between patients with H1N1 or H5N1 or Middle East Respiratory Syndrome (MERS), just as there is no way to differentiate between those with the deadly Ebola virus and those with a similar disease.
The impact of the repeated delays in implementing ICD-10 is being felt beyond our own borders. When the U.S. submits its data to the World Health Organization (WHO) for tracking these illnesses on the global stage, it first must be translated into ICD-10 so it will be comparable with data from the rest of the developed world. Because ICD-9 lacks the specificity of ICD-10, the translated data is generic in nature, which means the quality of U.S. information is subpar to that of many other nations – despite the fact that our advanced utilization of electronic health records (EHRs) has enabled us to collect far greater volumes of data than our foreign counterparts.
Impacts at Home
It may be easy to wave off high-profile, low-volume illnesses like Ebola and MERS as too rare to be considered seriously as it pertains to reasons to accelerate U.S. adoption of ICD-10, but they are nonetheless excellent examples of just how limited ICD-9 is as a code set. It is critical to be able to work with accurate and comprehensive data when tracking potential global epidemics and pandemics, and to be able to compare apples to apples when conducting research or tracking deadly outbreaks — just as it is when tracking for more narrowly defined population health issues.
The granular detail provided by ICD-10 enables early identification of incipient epidemics, such as the reemergence of measles and polio. Whether it’s influenza or enterovirus, Ebola or Chikungunya, to effectively track and treat, clinicians must be able to drill down into the data to look for specific variants or diseases to better understand how they are impacting patient populations. ICD-9 simply does not support this level of analysis.
Nor does ICD-9 facilitate the comprehensive level of documentation that lets us leverage coding to drive real-time decision-making. ICD-10 breaks conditions down and provides clinicians with much greater detail to work with, whether retrospectively or to drive clinical decision support.
Advancing Point-of-Care CDS
For example, if a patient’s problem list is maintained in the EHR and is coded using ICD-10, it drives more effective decision support at the point of care. It goes beyond standardizing vocabularies, which is only as good as the size of the vocabulary being used. ICD-10 provides the ability to describe patient encounters accurately and fully, in high-definition Technicolor, so to speak, rather than black and white.
If we can only say “other viral infection,” as is the case with Ebola in ICD-9, we’ve removed much of the detail regarding that patient’s history that tells the full story. It has been dumbed down to the point of near-uselessness. With ICD-10, you have the robust vocabulary you need to tell a powerful and accurate story that can be reported, shared, and analyzed.
Most importantly, with ICD-10 you have a level of detail that can be leveraged to advance patient care. ICD-10 enables location-specific trauma severity detail that is lacking in ICD-9, information that will move the U.S. healthcare system closer to a universal classification of injuries that more accurately details the resulting mortality risk and probability of residual impairment. For example, in ICD-9, a hand surgeon can code only “open hand fracture.” In ICD-10, with a single code, the detail expands to include, for example, “fifth metacarpal fracture,” “right,” and “postoperative visit.”
It is a level of detail that improves not only direct patient care, but also lends itself to better population health management. ICD-10 provides comprehensive, analyzable data that can be used to determine when and how injuries occur for surveillance purposes and to design injury prevention and control initiatives.
Another example of ICD-10’s superiority can be found in the patient record. More accurately coded data, stored within the EHR, can be used to generate on-the-fly clinical decision support, such as patient-specific order sets or a scenario in which a clinician is alerted to a possible emergent condition that would otherwise have been missed.
Driving Quality Improvements
Finally, ICD-10 has the potential to provide better data for use in improving quality of care. The robustness of the code set lends itself to data that better depicts severity and mortality, which is crucial to measuring clinician performance against patient outcomes.
The ability to do this has taken on greater urgency in light of the U.S. Department of Health and Human Services announcement that by the end of 2016, 30 percent of Medicare payments should be based on value provided versus quantity of service. By the end of 2018, that proportion should increase to 50 percent.
It’s an ambitious target for providers to hit, and it will be nearly impossible to do so when relying on ICD-9 codes for reporting.
Stop Delaying the Inevitable
Ebola may never return to the U.S., but its brief stay within our borders drove home the realities of just how much our healthcare system is limited by its adherence to ICD-9. Continuing to delay the inevitable move to ICD-10 is impacting our ability to drive population health at the local, national, and global levels. It is impacting our efforts to advance care quality and outcomes through improved decision-making at the point of care.
Simply put, ICD-9 has outlived its usefulness and is limiting our contributions to global healthcare.
About the Authors
Adam Lokeh, MD is a practicing plastic surgeon at Children’s Hospitals and Clinics of Minnesota and vice president of clinical development and informatics with Wolters Kluwer Health.
Kathy Lindstrom, RHIT, is a coding specialist with Wolters Kluwer Health.
Contact the Authors