ICD 10: Challenges for Family Physicians, Specialists

Although a lot of the buzz has drifted away from ICD-10 (for now) due to it’s delay, I cannot help but think about the challenges many physicians will face once October 1, 2015 finally comes. I often observe physicians while they search ICD-9 codes in the EHR to add to a patient’s chart while documenting a visit. I’ve also spoken with a few about what they think about ICD-10 and it’s implications. From my experiences, it’s apparent that most doctors aren’t very excited for the switch to ICD-10.

I believe physician resistance to ICD-10 can be boiled down to two core reasons:

1. Physicians don’t have the time to spend searching for specific codes. (laterality, status, manifestation) They’re already over-burdened with documenting in their ambulatory EHRs by having to check off dozens of boxes to satisfy Meaningful Use stages 1 and 2, Clinical Quality Measures, etc. Many specialists have a dozen or so ICD-9 codes memorized so they can just type them in and move on with the visit – this will no longer be feasible with ICD-10’s alphanumeric mix and increased code length.

2. Physicians don’t seem to even care about ICD-10. From their perspective: It makes their job harder – so what if it’s for better health reporting, “streamlined” billing, or research purposes – the bottom line is, it will undoubtedly take them more time to diagnose a patient via ICD-10 than ICD-9 using traditional search tools.

So, how do we address these problems?

I’m interested in seeing how EHR vendors proactively tackle this problem. I haven’t seen all the tools available (vendor-created and 3rd party) to physicians for coding in ICD-10, but my best guess is that they aren’t going to be free, and they aren’t going to be all that helpful.

I would love to see Computer Assisted Coding (CAC) find its way into the EHRs for ICD-10. Given many of the items (laterality, status, manifestations) physicians already check off or free text into the EHR, there’s plenty of available data to extract and use as “search refiners” when they click “Search For Diagnosis”. That way, if the doctor has already typed in or checked off information regarding the patient’s condition/side/status/manifestation and goes to click “Search For Diagnosis” – the results that populate are pre-filtered with the information provided in their documentation. Giving the doctors an easy way to populate as short of a list as possible is key, in my opinion.

I have seen this first hand – you give a doctor too long of a list of diagnosis codes and they will pick whichever one is the most general that way they aren’t technically wrong, and they can slide it by the payer (more about this in a later post). Since the goal of ICD-10 is detail, we need to set the physicians up for success.

The Good News: There are companies out there working on CAC solutions for ICD-9 and ICD-10. A notable example is Nuance’s Clintegrity 360, among others.

The Bad News: CAC solutions aren’t a built-in feature of any ambulatory EHR (to my knowledge), and will be an expensive add-on that physicians or physician groups will have to purchase in order to improve coding productivity. Ideally, EHR vendors need find a way to make this technology a component of their application suite at no extra charge.

Final Thoughts: Don’t get me wrong, I’m all for ICD-10… but the healthcare industry is in a very delicate position right now. ICD-10 needs to be implemented in a way that impacts provider’s workflow in the smallest way possible so they can focus on achieving Meaningful Use incentives, and most importantly, caring for their patients.


Google is building a smart contact lens for diabetics

Google X labs (where Google Glass was born) has started researching a smart contact lens for diabetics that would monitor glucose levels by the second, and give the user feedback via an LED light if glucose levels were on the rise or dropping. This project was recently discussed on the official Google Blog.

For diabetics, monitoring your glucose levels is a huge part of your everyday life. I know plenty of diabetics, many of which have a monitor clipped onto their waistband with a sensor fed underneath their skin. Along with this device, daily fingerpricks are also necessary. The are also many dangers associated with the incorrect or lack of blood glucose monitoring. Low blood sugar can cause you to pass out without warning, while high levels can be harmful to the body, leading to diabetic ketoacidosis (aka diabetic coma).

Some statistics show that 1 in 19 people are affected by diabetes (I’d bet it’s even higher in the US), and chronic diabetes patients (the people who are constantly monitoring) are estimated to make up 11% of  annual US health care costs. With the large share of healthcare spending that diabetes encapsulates, it is clear that a more efficient, easier way to monitor glucose levels may be a step in the right direction for both patient satisfaction and healthcare expenditures.

The data collected from the microchip embedded in these lenses could be extremely beneficial for diabetes researchers. This is the type of stuff that comes to mind when I hear “Big Data” in health care. If you were to do a study on 100 patients who wore the lens for 6 months and tracked their meals and activity levels, you would have over 1.5 billion data points on blood glucose levels alone. Aside from the research potentials of this device, real-time feedback on glucose levels would help diabetes patients stay within their limits and have less spikes or drops the result in expensive hospital trips.

Google X Labs is researching a smart lens that will give the user feedback on their blood glucose levels in real time.

Although this may not be ready for commercial use for a few years, it is great to see companies investing in health maintenance technology, the type of stuff that will reduce healthcare costs in the long run.

Opinion: Is the right EHR even out there yet?

An article I read today from Healthcare IT News talked about the problems yet another CIO faced when trying to select an EHR for his organization. The author of the article went on to pose the question, “Is the right EHR even out there yet?”

In one word: No.

Sure, there might be a really good EHR for small to medium pain management facilities, and a really good EHR for 1-3 physician family practices out there, but is there an EHR that is the right EHR for any given specialty or facility? No. You can’t place all the blame on the EHR vendors, though. With healthcare legislation playing a bigger role each day, I’m not surprised the “right” EHR isn’t out there yet.

Imagine you were trying to build the perfect EHR just 5 years ago. You probably thought you were coming up with all these awesome features to build into this perfect system: electronic order entry, letting doctors speak into microphones that transcribe their voices into text, a picture of the patient built into the system so you were sure you were documenting on the right patient chart, and ICD-9 codes built into the system! Maybe, for just a short moment, you had a nearly perfect EHR. But just a few years later, you learned that your EHR now had to track patient’s smoking status, keep an up-to-date problem list with current and past diagnoses, perform drug-allergy interaction checks, and a handful of other (Meaningful Use) measures. You spend lots of time and energy coding all these new features into your system, when lo and behold, a whole new list of things your must have are added. Now you’re coding in a feature that lets patient’s see their records (patient portal), and standardizing all your information into a format that can be sent to other organizations. Throw into the mix an entirely new diagnosis coding system (ICD-10) and some payment reform measures which must be considered, and now you’ve dug yourself quite a deep hole. Your once-perfect EHR is now a mess of data with checkboxes everywhere to cover all the bases. You haven’t had any time at all to consider usability so providers aren’t having to spend extra time finding all these fancy new checkboxes, and you’ve been throwing expensive new updates at them every few years.

I think its easy to see why the “right” EHR isn’t out there yet.

I do believe, however, that all these changes with regard to healthcare legislation will have a large impact on the number of EHRs able to maintain CCHIT certification, in turn reducing the number of options for CIOs and other decision makers in EHR selection (not saying that makes it any easier to make your selection…).

In reflection, this is something I hope to see in my professional career, the emergence of one or a select few EHRs that just, “have it all.” I would love to be part of a project like this; collaborating with an extensive team consisting of programmers, physicians, specialists, legislators, coders, and a dozen more healthcare role-players to research and start building the “right” EHR.

Smartphone Apps Increase Patient Health and Awareness

Until recently, I didn’t realize the huge market on the App Store and Google Play (android marketplace) for apps to diagnose or track patients health. Of course there are the apps that help you count calories and perform yoga or other training exercises, the apps i’m talking about are the types of things you might go to a doctor for. I was amazed when I found out you could get an extremely accurate heart rate reading in about 10 seconds with your iPhone! There is a free app called Heart Rate by Azumio that tells you what your heart rate is in very little time. The idea is simple: you place your index finger over the camera with light pressure while the app turns the LED flash on. The camera then detects the slight change in color with each rush of blood into your fingertip to determine your heart rate. If you don’t believe me, try it! Get out your smartphone and take a video (with the flash on) of your index finger lightly pressed against the camera, you can actually see the color change in your finger (albeit sleight!). If you fork over a whopping $0.99, you can track an unlimited number of heart rates, along with a new feature that measures your fitness level. I think tracking your heart rate over a long period of time could be very beneficial to someone who really cares about their health. If your heart rate climbs over the course of a few months it may be a sign of an unhealthy lifestyle or too much stress.

Another app, also by Azumio, called Sleep Time uses the iPhone’s accelerometer to track your sleeping patterns, and wake you up at the ideal time (i.e. when you aren’t in deep sleep). So instead of setting an exact time for an alarm, you set a window and the app wakes you at the lightest part of sleep in that window. When awoken during the lightest parts of your sleep, you wake up feeling well rested and ready to go. You would normally have to go to a sleep lab to get this type of wake-up treatment! Sleep Time is actually a free app for a limited time (so of course I just downloaded it) but is usually $0.99.

A third type of health-related apps that I find interesting are mole examination apps. There are a number of apps on both iPhone and Android marketplaces that claim to accurately distinguish cancerous from non-cancerous moles. I read a few articles a month or so ago pertaining to these apps and if patients can trust them (an issue i’ll cover later). Some of these apps use computer algorithms to diagnose a mole that you have taken a picture of. These are the least accurate apps for correctly diagnosing a mole’s malignancy (as low as 60% accuracy from what I remember). Other mole checking apps use real dermatologists to diagnose your mole. There is one app called Spot Check that is free to download, but you pay to get each mole diagnosed individually. After taking a picture of a mole, within a few days a board-certified dermatologist will examine the mole and give you a recommendation as to whether you should follow up or not. From the article I read a while back, this app had over a 90% accuracy rate in determining mole malignancy. I think an app like Spot Check could be very beneficial to someone who is on a managed care plan that cannot get access to a dermatologist without prior approval. Heck, in the future this may be the way a beneficiary obtains prior approval! This could also cut your medical expenses in situations where you go see a dermatologist and the mole turns out to be benign…. waste of time and money!

All these apps are great, and there are many more out there I didn’t mention. Now as a student studying Health Information Management… isn’t this all valid information for your medical record!? Also, if you have an incorrectly diagnosed mole by a dermatologist on Spot Check, isn’t that grounds for litigation!? I’m not the only one who has thought of these issues because there Congress is currently (yes, this week!) holding hearings on the FDA‘s role in regulating health apps for smartphones. It will be interesting to see what comes of this and I will definitely write another post when the final ruling comes out, which may take some time.

IBM’s Watson: Clinical Decision Making in Healthcare

I came across an article today that talked about IBM’s powerful thinking machine, Watson, and how “he” could be put to a practical use in the real world (aside from beating Jeopardy grand champions). One new possibility, which is already becoming a reality, is to have Watson help with clinical decision making in health care. According to IBM, only 20% of the knowledge physicians use to make their diagnosis and treatment decisions is evidenced-based. As a patient, that scares me. This means 80% of the physicians decision is based on intuition and prior experiences with somewhat similar cases. As a result of this, IBM states that 1 in 5 diagnoses are incorrect or incomplete. According to the Information Week article, this is the latest on Watson’s oncology learning diet:

Over the last year, Watson has been trained on more than 600,000 pieces of medical evidence and two million pages of text from 42 medical journals and clinical trials in the field of oncology. Sloan-Kettering has added details on 1,500 lung-cancer cases, training the technology to interpret physicians’ notes, lab results and clinical research on specialized treatments based on the genetics of tumors.

All this information has been added to Watson’s brain in just the last year. At this pace, Watson will soon have every published medical journal, clinical trial, and fragment of medical evidence stuffed into his mainframe.

IBM has developed an iPad app that can be used to find the best cancer treatment pathway for a given patient. Watson takes into account everything in the patient’s chart, and the physician can add new complications or conditions to the patient’s chart right within the app (they don’t even have to type it, Watson can comprehend your speech!). A short video on IBM’s website gives an amazing overview of just how powerful this app can be when diagnosing patients and selecting evidence-based treatment plans. Watson even gives a percentage indicating the level of confidence he has with each answer. Here is the video showing how the Watson iPad application works. I think it’s awesome, and in the future will be an extremely useful tool for providers to assist in clinical decision making.

First Post: A Video About Patients Involvement in Their Own Healthcare

This is a TED talk from a patient named Dave. After Dave’s unusual battle with cancer involving doctors that didn’t think there was a way to cure him, Dave became a big proponent of empowering patients. Dave found his cure by connecting with patients with the same terminal condition as him in other parts of the country.

Dave has a truly amazing story and he has now devoted his life to empowering patients.

Dave’s story is very unique. I know not every patient can find their ‘miracle cure’ by doing what he did, but that is not his goal. Patients that are more involved in their healthcare tend to care more about their health.