Strong leadership and strategic planning are helping hospital executives at UW Medicine get ready for new coding requirements—while enhancing integration across their system. 


At a Glance

To prepare for ICD-10 implementation, Seattle-based UW Medicine:

  • Conducted an impact assessment and a feasibility study
  • Built teams, selected leaders, and created a clear organizational structure
  • Collaborated with project teams that had similar goals, including those implementing computerized provider order entry
  • Developed physician education to drive compliance 

Careful strategic planning has helped leaders at University of Washington (UW) Medicine in Seattle respond to rapid changes in the healthcare environment. Yet UW Medicine, like many health systems, may be facing one of its most daunting challenges to date with the new coding changes that are part of ICD-10. The transition to ICD-10, which goes into effect Oct. 1, 2014, will have an impact on all aspects of the revenue cycle, as well as documentation, IT, and patient care.

The sheer size and scope of the system’s ICD-10 adoption plan is daunting: UW Medicine must mobilize thousands of physicians and residents spanning nine entities to adapt to a new, more exacting way of documenting care—without taking too much time from their extensive clinical, teaching, research, and administrative schedules and priorities. 

An Early Vision

In 2011, UW Medicine had the forethought to bring a dedicated ICD-10 program director on board and form a fully engaged support team. The charge of the program director has been to develop a master ICD-10 plan encompassing more than 300 separate projects, such as more than 100 IT system upgrades, electronic health record (EHR) configurations, and revisions to clinical documentation. The master plan is designed to support the strategic objectives of the organization, including the primary focus: full integration. 

Leaders at UW Medicine view the ICD-10 initiative as a defining catalyst to reduce redundancy, improve communications, tighten documentation, and achieve operational efficiencies across many departments and entities. In essence, the system is using ICD-10 as an opportunity to further clinical integration and transform care across all service lines and clinical functions. 

Coming to Terms with ICD-10 

In mid-2011, a team composed of the CFO, CIO, vice presidents, and executive and medical directors from each entity embarked on an impact assessment to ascertain the scope of the ICD-10 effort. Key objectives of the assessment were to:

  • Determine how best to form ICD-10 teams
  • Decide which projects would be needed to fulfill an ICD-10 transition program
  • Identify risks
  • Establish the type of budget— and effort—that would be needed to achieve success as an integrated organization 

The team was able to achieve these objectives by reviewing workflows, financial reporting, staffing volumes, organization structures, policies and procedures, and quality metrics. Leadership and subject matter experts were interviewed to discuss concerns and competing priorities. 

When completed, the assessment disclosed some jaw-dropping findings, the most astounding of which was that the transition would require a considerable, multimillion-dollar budget and “affect everything and everyone—except for parking and security,” as one hospital leader noted. 

After completing the impact assessment, the ICD-10 Program team developed a feasibility study to flesh out how the different projects under the ICD-10 plan could be accomplished in time for the national transition date. 

Through the feasibility study, the team also identified other benefits from the move to ICD-10 that would help support the urgency and value of the project. These additional benefits included the following. 

Quality and safety. The new language requires that every report, clinical trigger, patient safety goal, dashboard, and myriad mandates that currently use ICD-9 be reviewed and revised. Such a review is bound to promote improvements in the quality and safety of patient care.

Business intelligence. Understanding the relationship between ICD-9 and ICD-10 codes and managing the transition effectively will ensure that hospital leaders can utilize their data in the months following the ICD-10 transition. It is not possible to simply “replace” codes; decisions must be made based on which codes are used and how they are used. If reports using ICD-9 codes are not rewritten, the data will be lost after the transition.  

Clinical and operational alignment. Documenting with greater specificity may facilitate more consistent patient care and operational practices across all UW Medicine entities, thereby promoting greater organizational strength, clinical excellence, and patient safety along the continuum of care.

Payment. Collaborating with payers early and often both strengthens relationships and provides better information to effectively mitigate known risks. Common testing definitions of clinical scenarios and risk areas also will support more accurate claims, leading to fewer denials and faster response time when issues arise. 

Organizing the Effort

UW Medicine’s executives understood that a program of this scale—one with many moving parts that affects employees at all levels—would need strong leadership as well as clearly defined roles and responsibilities. Specifically, the ICD-10 program would require:

  • Central leadership with strong stakeholder involvement
  • A program team that is integrated and aligned with stakeholders to ensure that the planning, design, and implementation are performed from a systemwide perspective
  • A program director who would have control over the resources required to implement the plan 
  • A clear path for escalating decisions and resolving issues 

To that end, hospital leaders established a clear organizational structure for its ICD-10 program, led by a program director who reports to the program’s sponsors in UW Medicine’s executive suite. Reporting to the program director are senior project managers representing six major areas of impact: 

  • Clinical operations
  • Physician engagement
  • Revenue cycle/finance
  • Coding and clinical documentation improvement
  • Technology
  • Data and reporting 

Across each of these areas, additional project managers also must address cross-functional areas of impact:

  • Education and training
  • Testing
  • EHRs
  • Communication and change management
  • ICD-10 coding readiness 

Overall, about 25 people on the ICD-10 team report to the program director. Leaders designed this structure to minimize oversight redundancy and ensure appropriate leadership from each UW Medicine entity. 

The program’s central governing body is the ICD-10 executive steering committee. This committee is co-chaired by the executive sponsors for the program, Lori Mitchell, CFO, UW Medicine and vice president for medical affairs, University of Washington, and James Fine, MD, professor and chairman, laboratory medicine and CIO, IT services, UW Medicine. 

The executive steering committee is charged with keeping the ICD-10 program focused and on schedule. Its goals are to ensure adequate resources for the project, remove barriers to implementation, and facilitate communication throughout the organization. 

Mitchell and Fine were natural choices for leading the ICD-10 effort because they had successfully led a 2010 billing system conversion, which followed a similar implementation strategy. 

“Jim and I are engaged in this process on a daily basis,” says Mitchell. To address major issues or decisions, Mitchell and Fine have established a formal remediation process. “We ask any groups or individuals voicing concerns to put those issues into a formal white paper,’” Mitchell says. “We review that report, get the facts, and meet with them to resolve any brewing problems and find a resolution.” 

Exhibit 

Lucas_Exhibit

Integrated Approach Takes Form

When conducting the feasibility study, the ICD-10 team looked at strategic initiatives across the organization, including implementations of computerized provider order entry (CPOE) and a new ambulatory EHR, efforts to achieve meaningful use, and integration efforts across the system. 

It became apparent to the ICD-10 team that many of these projects had overlapping impacts and were competing for resources. Why not take advantage of that overlap and find common points for collaboration? 

For example, hospital leaders found that the ambulatory EHR team was focused, of course, on EHR implementation. Yet when the ICD-10 team met with the EHR team, the groups uncovered ways to coordinate their efforts in design sessions and training of end users. 

Implementation of CPOE in ambulatory oncology clinics was another area in which collaboration was possible. As part of this process, the CPOE team is preparing to update and standardize order sets. Similarly, ICD-10 will require a review of the order sets to ensure the sets support the coding language. As a result, leaders at UW Medicine have created a complementary, concurrent timeline for the CPOE and ICD-10 order set reviews. Overall, our CPOE and ICD-10 teams will be able to utilize fewer resources, reduce clinical disruption, and roll out the new changes to physicians only once.  

In looking at the range of projects and workflows across UW Medicine, the ICD-10 team saw more and more opportunities to interlink projects at defined points. Usually, organizations try to avoid “scope creep,” but in UW Medicine’s situation, the goal was to bridge projects that had similar impacts. 

Because ICD-10 touches everyone, it also is an impetus for driving integrative work. UW Medicine’s ICD-10 program has strengthened what can be a tenuous relationship between coders and clinical documentation improvement (CDI) professionals. Across the medical centers, these groups have created a common understanding of what “coding” includes, standardized education and auditing requirements, and defined staffing ratios. Now, they make decisions and collaborate as a team. 

Communicating the Continuum-of-Care Benefit

Another challenge for UW Medicine is creating ICD-10 training that can connect with faculty and affiliated physicians, as well as medical students, residents, and fellows in training.  

“We need to give our physicians and other staff as many tools as possible to make it easier for them to learn and adapt to ICD-10,” Mitchell says. “There is not going to be an ‘opt out’ for this program, so we need to make this as easy as possible.” 

The ICD-10 program developed a three-pronged strategy to gain physician buy-in. The plan is to drive physician compliance from a quality and patient care focus, and include all physicians, department heads, and medical directors in coordinated ICD-10 messaging.  

Moreover, as with the other projects, the use of existing resources provides a means to reduce the burden on physicians. For example, during a meeting in 2011 with the practice plan billing and compliance team and its compliance officer, the ICD-10 program director learned that an established compliance and billing training program existed in UW Medicine’s learning management system (LMS), with nearly 50 online modules covering specialty-specific areas. The program director decided to use this infrastructure for ICD-10 training because physicians were already familiar with the LMS and, thus, would be more receptive to it.  

The LMS allows employees to take classes at their own pace. Mitchell also observes that the system “will help us keep track of who has completed training and help us know if we are meeting our training goals.” 

Leaders at UW Medicine also recognized that physicians tend to learn best from other physicians, in a peer-to-peer manner. In the future, ICD-10 specialty and subspecialty content will be delivered to physicians, by physicians. 

The next challenge will be to integrate training on facility and professional billing, including the outpatient and inpatient components of physician billing. One objective of this training, for example, is to help physicians to understand that ICD-10 and the call for greater specificity in documentation benefit them just as much as the facility.  

Broadly, physician education will focus on two important themes: First, “If you don’t document it, it didn’t happen.” Second, accurate documentation has an important impact on the continuum of care for patients to ensure all providers involved in complex care have ready access to consistent information, as well as the physician’s own profile and billing. 

According to the needs of an academic medical center, leaders at UW Medicine plan to provide an integrated approach for medical students, residents, and fellows in training for Current Procedural Terminology and evaluation and management coding processes as well as ICD-10. To be successful clinicians, these individuals will need to capture severity of illness and document clinical conditions and procedures. The program also is intended to help practicing physicians enhance the accuracy of professional billing and ICD-10 compliance to maintain the viability of their practice in the coming years.

These initiatives are complementary—rather than competitive—aspects of the current regulatory and payment system. Physicians also may see that this push for more detailed documentation could lead to enhanced data for clinical research, epidemiologic analysis, and healthcare policymaking. 

Lessons Learned 

The road to implementing ICD-10 is long and challenging, but UW Medicine will be stronger and more united once it’s all said and done. (A timeline of the initiative, with major milestones.) 

Along the way, UW Medicine has identified best practices that help ease the transition. 

Communicate early and often. The ICD-10 team presented at existing governance forums and held ICD-10 departmental workshops that attracted almost 500 attendees. The team’s goal was to present the facts about ICD-10, highlighting the clinical benefits. To further improve communication, leaders at UW Medicine also have built an ICD-10 intranet site. However, some employees may still feel that ICD-10 “is being inflicted on them,” so the challenge is to show that ICD-10 offers strategic opportunities—namely, the ability to improve clinical integration. 

Partner with your payers early and often. ICD-10 trained coders at UW Medicine are coding charts in ICD-10 and sharing that work with payers to conduct joint evaluation and testing. This step gives both parties time to understand how the language and codes will change within a specific population so they can effectively prepare for the transition. 

Embrace responsible scope creep. Traditionally, organizations don’t want projects to meld into one another. However, with the cost and time associated with ICD-10 preparation, finding those connection points among projects helps minimize the impact on clinicians and patients. 

Choose the right leaders. Select engaged executive leaders as well as a project leader who has the experience to tackle such a large program. Leaders at UW Medicine have chosen two executive sponsors who are known for handling large projects and being thoughtful and collaborative. They also are committed to showing a united front and making the hard decisions. 

Partner with physicians. Physician leaders should be fully engaged in the ICD-10 conversion. Education for physicians should be focused by specialty or subspecialty and should be delivered peer-to-peer. It should also embrace existing technologies, as UW Medicine did with its LMS. 

Racing Toward 2014

Many have just left the starting block on the ICD-10 implementation, and the finish line in 2014 seems far off. But UW Medicine’s leaders believe that,­­­ with the right planning, training, and commitment, the health system will end up even stronger and better than before. The push to achieve ICD-10 readiness as a team will foster a common understanding of what is going on across the organization at all levels, in all departments, and in all systems, leading to true clinical integration. In that respect, this is truly an opportunity of a lifetime.


Sarah Lucas is ICD-10 program director, UW Medicine, Seattle, and a member of HFMA’s Washington-Alaska Chapter (slucas2@wu.edu).


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About UW Medicine 

Located in Seattle, UW Medicine is a comprehensive healthcare system that comprises eight entities: Harborview Medical Center, UW Medical Center, Northwest Hospital, Valley Medical Center, UW Neighborhood Clinics, UW Physicians, UW School of Medicine, and Airlift Northwest. UW Medicine is also one-third owner of the Seattle Cancer Care Alliance with Fred Hutchinson Cancer Research Center and Seattle Children’s Hospital. UW Medicine serves as the only academic health system and medical school in the five-state region of Washington, Wyoming, Alaska, Montana, and Idaho. 

UW Medicine’s mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary, secondary, tertiary, and quaternary care for the region, and teaching and preparing the next generation of physicians and healthcare professionals.

 

Publication Date: Tuesday, January 01, 2013

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