The ICD-9 medical coding system we’ve all relied on for decades will soon change—and it’s not going to be an easy or cost-free transition for most of us. The new system, ICD-10, is a radical departure from ICD-9, under which the number of diagnosis and procedure codes will increase from approximately 16,000 to more than 155,000. For many of us who use the same hundred or so codes all the time, the reasons behind why the code set will expand tenfold are difficult to comprehend and feel like more of the same bureaucracy that has brought us HIPAA and CCHIT. 

Because there aren’t thousands of new disease states, most of the new codes are sub-sub divisions of existing codes designed to capture more detail. For example, consider a patient who comes in with a sore throat. In ICD-9, the physician would likely code a 462 as the diagnosis (Acute pharyngitis, which includes most common iterations, such as suppurative, infective, and not otherwise specified [NOS] and excludes about a dozen others, such as abscess, chronic, Mono, flu, and Strep). Coding the same patient under ICD-10 would require the physician to choose from among four codes that differentiate between an acute sore throat, Strep, other causes, and NOS, each of which has inclusions and exclusions as well, leading to a decision tree containing dozens of sub-choices. Another example is coding an ankle sprain. With ICD-9, there are five detailed codes essentially locating which ligament is involved (845.xx). In the ICD-10 code set, however, you end up with 45 codes. The additional codes allow the provider to describe, among other things, the location of injury on the ankle joint, the degree of injury, whether it is a first-time injury, and cause of injury. 

Considering there will be increases in coding categories across the board, documenting and coding simple diagnoses will require much more physician decision making. Proponents of the new system argue that it will improve the quality of patient care, help track outcomes and other vital information used for research and distribution of prevention resources, and provide a more rational approach to payment systems. Sounds great, but who is going to pay me for this extra time and work, or for the EHR that can figure this out behind the scenes? For physicians like me with small medical practices, ICD-10 represents the frightening prospect of a steep learning curve, more coding and billing errors, and figuring out how to capture and record more clinical information during the course of an already too-short patient visit. 

What’s the answer? One option is to not play the game at all and refuse to accept third-party payments, though most of us likely don’t have the stomach for this level of dissent (But can you imagine a world in which patients paid you directly and then had access to affordable catastrophic insurance for additional needs?). But that’s a discussion for a future article… 

More likely, we’ll need to adopt complex EHR software that can help us do the coding. Based on how most of us use ICD-9, I suspect we’ll just end up with a tenfold increase in incorrect codes that don’t really describe the true nature of the diagnosis. Even worse, this further degrades the doctor—patient relationship as the patient becomes more of a traceable and codified commodity, whose numeric summary further moves them away from what most patients (and their providers) really want: an honest, straightforward relationship with a well-educated physician who can provide logical guidance in dealing not only with sore throats and ankle sprains, but also childbirth and rearing, anxieties and depression, and, perhaps most importantly, end-of-life issues. Isn’t that why most of us went into this field in the first place? 

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/ Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts. com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

Articles

The ICD-9 medical coding system we’ve all relied on for decades will soon change.

Code Overload

Remember in the 1960s Star Trek series when Dr. McCoy would pass his medical tricorder over a prostrate body to discover not only which species of alien had invaded the young ensign, but also how to expel the creature with a dose of medicine? McCoy’s tricorder combined both a universal diagnostic device and a medical information database of boundless proportions. Who could want anything more? 

That futuristic vision of point-of-care information technology is still a long way off, but the concept was a remarkably accurate prediction of where we are heading today. “Point-of-care” is an amorphous concept that changes depending on your point of view. For small medical practices, point-of-care generally means providing evidence-based medical advice to physicians as they are diagnosing and developing their plan of action. Information sources range from reference materials to patient records to drug reference tools and so on.

Until the 1990s, many primary care practices relied on textbooks, and later, referenceable CD-ROMs. But as we were forced to see more patients in a shorter amount of time to make ends meet, we moved to more concise, pocket-sized guides that summarized the important facts. Those guides are now being supplanted by applications and databases that run on tablets, handhelds (like PDAs and PalmTreos), and increasingly on smartphones (like the BlackBerry, iPhone, and the new G1 running on Google’s open mobile phone platform called Android).

There are three different models for point-of-care information delivery: static, push, and pull. With one of the most popular mobile point-of-care applications ever, 

—a free drug and formulary reference&mdash;users download a fixed database that resides on their device. The database is not updated until the user downloads a new version. On the other hand, 

 (5MCC) Online provides instant access to the essentials of 700+ medical conditions. Users “pull” information, including dermatology images, videos of medical procedures, AAFP patient handouts, and more. By contrast, Skyscape’s MedAlert “pushes” up-to-the-minute clinical information, such as drug updates, journal summaries, and clinical trial results by specialty, to a cell phone, smartphone, PDA, or desktop.

With the addition of wireless networking technology, healthcare providers can get real-time, point-of-care information on differential diagnosis, testing, and treatment options as they see the patient and come up with the plan. The power to hop onto Google and search for any subject puts a virtually unlimited source of information right at our fingertips, although sorting through the data to differentiate the wheat from the chaff remains the most difficult aspect of such a plethora of information.

Of course, short of simply knowing the information from our extensive training and continuing medical education, the most logical way to be presented with this medical data is through our electronic health record during the patient encounter. This is the actual point-of-care, and having evidence-based information pop up in one’s EHR at that moment would be remarkable.

The EHR could intelligently and proactively retrieve pertinent information as demographics, symptoms, vital signs, and other relevant data is entered into the patient’s chart. This data could be analyzed behind the scenes, patterns could be recognized, and recommendations presented to the physician.

As we gaze ever further into the future, perhaps to when intergalactic space travel or beaming ourselves from room-to-room is actually possible, physicians may someday have chips containing all of the known information about health and the medical sciences embedded into their brains. Until that time arrives—may you live long and prosper.

What point-of-care references and diagnostic aids do you use? Are you satisfi ed with the products currently on the market?

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of EHR software. He is also the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Remember in the 1960s Star Trek series when Dr. McCoy would pass his medical tricorder over a prostrate body to discover not only which species of alien had invaded the young ensign, but also how to expel the creature with a dose of medicine? 

Tech Talk: Point-of-Care Information

Although I am known as a techie, I am not much of a gadget guy. My office does not employ any “exotic” equipment, other than standard medical instruments, desktop and laptop computers, printers, and of course an EHR. At home, my family and I tend to be late adopters, waiting to purchase a tech product or device until it has been proven in the market and comes down in price. But we do have several favorite “can’t live without” devices, even though they are probably well known to most people. 

If you watch television and you haven’t started using a digital video recorder (DVR) yet, you need to take a closer look at what this gadget can do for your life. DVRs are basically giant disk drives (similar to the one in a computer) used to record TV shows. The first and most wellknown DVR was TiVo, though nowadays, most cable and satellite providers have their own DVRs built into their settop box. Depending on the size of your DVR’s hard drive, you can record dozens or even hundreds of hours of programming. Better yet, these devices allow you to pause and rewind live television, fast-forward through commercials, and record a season’s worth of shows with the press of a button.

What’s really great about DVRs is their ability to “timeshift” your television watching. This is a fancy way of saying that you can watch the shows you want anytime, instead of when the network programs them. For example, when my wife and I sit down to watch television after the kids have gone to sleep, we don’t just flip channels until we find something interesting and then sit through interminable commercials; instead, we look at the list of shows prerecorded on the DVR and then select whatever we want to watch. We skip the commercials, cutting 20 minutes off an hour-long show. Our children benefit as well, since we can be more thoughtful about what they watch, choosing educational and enriching shows in advance so there is always something good for them to watch. Basically, I won’t watch live TV since being introduced to the DVR.

Another family favorite is satellite radio, which has numerous advantages over plain-old terrestrial radio, starting with the outstanding programming. There is a channel for nearly every genre of music out there. It goes way beyond the typical rock and country fare found on FM and AM stations. Enjoy listening to bluegrass or reggae? How about opera or gospel? The channels for kids are great for long trips, as is the classic radio show channel. Speaking of road trips, one of the best things about owning a satellite radio is being able listen to the same stations from coast to coast. In addition to music, satellite radio offers a plethora of sporting event broadcasts; talk shows; news from CNN, BBC, NPR, CNBC, etc; and 24/7 weather and traffic. Personally, I love jumping from joke to joke through the various comedy stations (though, on family trips this can be a bit difficult, because many of these channels are unedited, and cursing is common).

The last gadget on my short list of tried-and-true products is the wireless data networking card for my laptop computer. I travel a lot in my role as president of AmazingCharts.com, and I cannot always count on getting access to a wireless network hot spot. Wireless data networking “AirCards” plug into a laptop using a USB port, PCMCIA card slot, or an ExpressCard slot. I use Sprint for the data service and have found it to be signifi cantly faster than Verizon, but you should research which carrier provides the best coverage in the geographic areas where you plan to use your laptop most.

AirCards first look for a WiFi connection, and if they can’t find one, they connect to the wireless service carrier’s data network using cell phone technology. Theoretically, with AirCards, you could stand in the middle of Death Valley and still be able to surf the Internet and send e-mail. The truth, though, is that service coverage can be spotty, particularly in remote areas. The carriers promise “broadband speeds where available,” but you will think it crawls compared to your high-speed connection at home or the office. Still, it is better than no Internet access.

If you watch television and you haven't started using a digital video recorder yet, you need to take a closer look at what this gadget can do for your life.

Tech Talk: Great Gadgets

	I'm talking about the End User License Agreement (EULA) that comes with each software program on your computer. I must confess that in the past I almost never read EULAs either, especially when installing a new version of consumer software from well-known vendors like Adobe, Apple, and Microsoft. The EULA is a legally binding contract that spells out the terms under which an end user may utilize a software program. Most EULAs are presented electronically, during software installation, and off er you two choices: accept or refuse. Of course, not accepting the EULA means you can’t install the software. 

	The terms outlined in the EULAs are very important when it comes to critical business software. Few programs are as critical to a physician practice as the Electronic Health Record (EHR). Because EHRs contain the medical records of patients, they are subject to a wide range of laws, including federal HIPAA and privacy regulations and state mandates regarding how long medical records must be kept on file after a physician retires or a patient dies. The EHR EULA often addresses many of these requirements.

	But beyond this, the EULA has become the software vendor’s legal armor, requiring users to waive more rights than you can imagine. The EULA is essentially non-negotiable—either you accept it or you cannot install and use the software. Unfortunately for end users, EULAs are designed to provide maximum protection for vendors while minimizing the legal options and remedies for users who are dissatisfi ed with the product. Nearly every EULA I have ever seen includes the following paragraph:

	THIS PRODUCT IS PROVIDED TO YOU “AS IS” WITHOUT WARRANTY OF ANY KIND, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHERWISE. THIS COMPANY AND ITS LICENSORS BEAR NO LIABILITY FOR ANY DAMAGES RESULTING FROM USE (OR ATTEMPTED USE) OF THE PRODUCT.

	When you click on the button to accept the EULA on your way to installing software, you are agreeing to assume all risks, no matter what the software does, doesn’t do, or does wrong.

) also had a strongly worded, attorney-written EULA. Although 99.9% of our users simply accepted this, a vocal 0.1% decided to speak up, and made their dissatisfaction known on our company-sponsored 

. The subject also came up at our recent users’ group conference, which gave me the opportunity to understand fi rsthand how strongly people felt about this issue. It turns out they had a point, and what they wanted seemed completely reasonable.

	Our clients wanted to ensure that the clinical data being generated and saved to the program’s database belonged to them. They were concerned that if my company went out of business, or if they wanted to move to another program (which doesn’t happen often), they would be guaranteed access to their data, and be able to get it without paying for it. Believe it or not, most EHRs don’t release your clinical data without requiring thousands of dollars in “ransom.” Although Amazing Charts has always allowed customers to export their clinical data, these users wanted this spelled out in the EULA. Our customers also wanted the EULA to guarantee our EHR wouldn’t use spyware or provide their prescription and other clinical habits to any third parties, such as insurers, pharma, or the government.

	Based on this feedback, we’ve rewritten our own EULA to refl ect our clients’ concerns and clearly state the key concepts usually obscured by legalese (you can read our latest attempt on our user board). Because most of us don’t make a decision to use one program over another based on the fairness of the EULA, this hasn’t yet become one of the methods potential customers use to evaluate EHR systems. However, I suggest you take the time to actually read the EULA before you click “I Accept.” You might be surprised by what you find there.

One of the most important legal documents in your practice may have a significant impact on your finances. And even though you (or someone in your practice) agreed to abide by its terms and conditions, it's highly likely that you have never even read it.

Jonathan Bertman, MD, FAAFP

Articles

Code Overload

Tech Talk: Point-of-Care Information

Tech Talk: Great Gadgets

Tech Talk: The Contract You Never Read