May 18, 2015
Failure to Address Physician ICD-10 Concerns, Misalignment of Federal Health IT Priorities are Strategic Blunders
This article was originally published in Digitized Medicine on May 18, 2015. Reprinted with permission.
Texas Representative Ted Poe has introduced H.R. 2126, the Cutting Costly Codes Act of 2015. This legislation would prohibit the federal government from requiring physician offices to comply with the proposed transition to ICD-10 codes. “The new ICD-10 codes will not make one patient healthier," Representative Poe said. "What it will do is put an unnecessary strain on the medical community who should be focused on treating patients, not implementing a whole new bureaucratic language.” He has clearly listened to the Texas Medical Association (TMA) which has consistently advocated for postponement of ICD-10 on behalf of 48,000 physician members.
I am one of those Texas physicians who is thankful that a congressman has listened to us. If this bill were passed it would postpone ICD-10 and call for the GAO to study the issue, but it does not propose any solutions. Although I am in favor of this bill, I agree with the cry of many healthcare stakeholders that we need a solution to move away from the antiquated ICD-9 codes. It seems likely that a bill that does not propose an alternative solution will have difficulty getting passed.
I am hopeful, though, that debate about this bill might illuminate two major flaws in national health IT strategic planning. The current ICD-X strategy which includes no roadmap to ICD-11 will set up the U.S. healthcare industry for strife and conflict in the 2020s when we see the rest of the world leveraging integration between ICD-11 and SNOMED to improve quality of care and control costs while we struggle to gain value from what will then be an antiquated ICD-10 coding system.
The first flaw is the lack of a strategic plan or roadmap at a national level for ICD-X conversions. For example, there is no mention of ICD-10 or ICD-11 planning in ONC's federal health IT strategic plan 2015-2020. It is difficult to trust a strategic plan that fails to account for the tremendous burden that an ICD-10 and/or ICD-11 conversion brings to the healthcare industry. The ICD-10 tactical delays can be directly attributed to conflicting strategic national healthcare priorities which resulted in an overlap of initiatives at the local level, such as the Meaningful Use Program and e-prescribing requirements, and created unreasonable, concurrent burdens on physicians. Tactical delays like this can be avoided through more effective strategic planning at the national level.
It is particularly disconcerting that there is no national roadmap to ICD-11. As I previously wrote, the U.S. is planning to achieve a short-term tactical goal of replacing antiquated ICD-9 codes while the rest of the world is closing in on their long-term strategic goal of implementing ICD-11. Informatics experts are in agreement that ICD-11 is superior to ICD-10 and is much more integrated with SNOMED codes. Unless we develop a long-term ICD-11 strategy, we are destined to be in the same predicament in the 2020s when we will be struggling with a tactical goal to get off of last century’s ICD-10 with no roadmap in place to align that effort with other healthcare priorities.
The second flaw is the lack of an effective process during ICD-X conversion planning to identify and address the concerns of grass root physicians who see patients every day. Failing to address physician concerns prior to developing the ICD-10 solution to the replacement of ICD-9 was a strategic blunder. Perhaps the most significant physician concern is the tremendous burden placed on physician practices by the ICD-10 conversion. Optimal planning on how to replace antiquated ICD-9 codes really should include discussions on how we might best reduce or avoid that burden. At the very least, we should discuss how best to reduce that burden in the future, because physicians see ICD-11 coming around the corner.
For example, we should discuss the possibility of converting from use of ICD-9 or ICD-10 to use of SNOMED codes in physician practices. Physicians would not have to learn new ICD-X codes each time administrators decide a conversion is necessary. Use of SNOMED codes mapped to ICD-X codes would be less disruptive to physician work flow and be more cost effective for physician practices as compared to complying with future ICD-X conversion mandates.
The analysis on how best to resolve the ICD-9 problem should address physician concerns and result in a strategic plan that is determined to have the highest potential to improve healthcare quality at the lowest cost. So what are some attributes of the optimal strategic planning effort? It would be included in ONC's federal health IT strategic plan. It would include a national roadmap to ICD-11. It would include a comparative analysis of the cost/benefits of completing a conversion of ICD-10 versus a direct conversion from ICD-9 to ICD-11. It would include an analysis of the potential to replace ICD-9 or ICD-10 codes in physician practices with SNOMED codes. And it would include a process to identify and address the concerns of physician practices throughout the planning stages.
Mar 19, 2015
Mar 17, 2015
- Americans for Tax Reform: The Conservative Argument for a Permanent Medicare Doc Fix
- Wall Street Journal: Bouncing the ‘Doc Fix’ -- Faux fiscal hawks may scuttle modest but real entitlement reform.
- American Action Forum: Merits of the Proposed SGR Repeal
- Forbes: Real Entitlement Reform With The Doc Fix Repeal, by Grace-Marie Turner
- National Center for Policy Analysis: Paying for the Medicare “Doc Fix”, by Devon Herrick
Feb 8, 2015
A snapshot of a few of the 300 physicians, medical students, and TMA Alliance members who came to be lobbyists for a day at the February 2015 First Tuesdays at the Capitol.
Register now for the March 3 First Tuesdays.
Feb 5, 2015
Texas Physicians to Benefit from First-Of-Its Kind Organization Created by Texas Medical Association and Blue Cross and Blue Shield of Texas
TMA PracticeEdge to Offer Physicians Options to Remain Independent
The Texas Medical Association (TMA) and Blue Cross and Blue Shield of Texas (BCBSTX) are launching TMA PracticeEdge to help empower a strong base of independent physicians to provide quality, cost-effective care to their patients. This first-of-its kind joint effort leverages the strengths of TMA’s statewide physician membership and BCBSTX’s resources to benefit the entire Texas health care community, including patients, hospitals, payers, and other physicians.
TMA’s membership includes more than 48,000 Texas physicians and medical students. BCBSTX serves more than 5 million members in all 254 Texas counties.
TMA PracticeEdge, LLC, will offer physicians access to enhanced patient care tools and resources so they can better provide cost-effective patient care. Physicians working with TMA PracticeEdge will be able to take advantage of the opportunities available in the rapidly changing health care marketplace.
TMA and BCBSTX share the goals of increased quality and cost-effective care found in existing physician-led accountable care organizations (ACOs). TMA PracticeEdge similarly will provide tools to reduce physicians’ growing data-entry burden to allow them to focus on taking care of their patients. The goal is to establish a system that pays physicians and providers based on the quality of patient outcomes and patient care.
While most ACOs are constrained by a specific hospital system, TMA PracticeEdge will help connect physicians centered on the needs of their specific patients. TMA PracticeEdge will offer participating physicians the means to provide coordinated collaborative care, including prevention and management of chronic disease.
According to the 2014 TMA Survey of Texas Physicians, approximately two-thirds of Texas physicians work for themselves or in practices that are wholly owned and controlled by other physicians. Most of these independent physicians traditionally have not had access to the tools and resources needed to participate in an ACO.
“BCBSTX will work with TMA to give physicians alternatives to today’s fee-for-service system,” said TMA President Austin I. King, MD. “With today’s announcement, BCBSTX becomes the first health insurer to stand by independent Texas physicians in support of 21st century patient care.”
“This represents a significant investment in our relationship with the TMA and Texas physicians, and will benefit our members, who value their relationships with their independent physicians,” said Bert Marshall, President of Blue Cross and Blue Shield of Texas.
TMA PracticeEdge will help physicians lead health care innovation in today’s evolving marketplace. PracticeEdge will offer participating physicians several services, including:
- Consultations to help reduce administrative burdens so they can spend more time focusing on patient care.
- Help for practices wishing to create care management teams to better serve patients with complex or chronic health problems.
Physicians and office managers who are interested in learning more about TMA PracticeEdge should contact TMAPracticeEdge@texmed.org by email.
Feb 3, 2015
Nov 14, 2014
By Brian B. Rogers1, DO, MPH; David M. Weitzman1,3, MD; Gregory S. Buzard2, PhD; Alexandra Boyd-Rogers
Publisher's Note: Dr. Rogers and his colleagues prepared these protocols to help physicians prepare to respond to suspected cases of Ebola virus. The contents have been edited for style and readability, but have not been reviewed by TMA for scientific accuracy.
I write to you from the "New Hot Zone," just a few miles from the newly famous Dallas Presbyterian Hospital. Like many of you in our field, I have been attempting to put together coherent protocols for addressing the potential Ebola cases that might arrive at our facilities from the often conflicting and scattered breadth of information available online. Making a synthesis of all suggestions by using the best information currently available on the CDC website, I have prepared an updated and comprehensive guide for Urgent and Primary Care Physicians. As a former Public Health Officer, I have chosen a conservative approach to these guidelines, preferring to err on the side of caution where Federal suggestions vary.
This article will cover:
- How to determine if a patient is a potential Ebola case
- What to do once you decide a patient might be an Ebola case
- What to do if the patient requires life-saving procedures
- What to do in the event of staff exposure
- How to get the patient into the right hands for specialized and extended care
Determining if Your Patient is a Potential Ebola Threat
Symptoms of Ebola (if your patient has one or more of the following):
- Fever (prolonged or spiking) greater than 38.0° C (100.4° F)1
- Generalized Muscle Pain
- Generalized Abdominal Pain
- Unexplained Bruising or Bleeding2
- Patient has had percutaneous, mucosal, or direct skin contact with blood or body fluids (including sweat, saliva, semen, vomit, fecal material, etc.) of a confirmed Ebola victim
- Patient has processed blood or body fluids of a confirmed Ebola victim
- Patient has had direct contact with a dead body (as part of funeral rites, embalming, or body handling prior to cremation) of a suspected Ebola case in an outbreak-confirmed country or area
- Being within approximately 1 meter (3 feet) of an active-case Ebola patient
- Being within an Ebola victim's room or care area for an extended period of time
- Making direct or brief contact (shaking hands, physical exam) with an Ebola victim
No Known Exposure:
- Having been in a country or facility with known Ebola patient(s) within 30 days BUT having had no high-risk or low-risk exposure2
If a patient is SYMPTOMATIC (fever OR other symptoms) AND fits into one of the above categories, IMMEDIATELY report the case to your local health department and infection control officer. Follow their directions regarding the immediate isolation and transportation of the patient OR the relay of conditional release/controlled movement* information to the patient.
If a high-risk or low-risk patient is ASYMPTOMATIC (low-grade or no fever AND lacks other symptoms) at presentation, STILL report the case to your local health department for directives regarding the relay of conditional release/controlled movement information to the patient.
If a patient is of the NO KNOWN EXPOSURE category and is ASYMPTOMATIC (NO fever AND lacks other symptoms), provide and discuss written self-monitoring instructions with the patient.
*Persons who are 'conditionally released' should self-monitor for fever and all other symptoms twice daily for a conservative minimum of 21 days beyond the last possible exposure date. They should report all potentially relevant temperature or symptom changes to a public health authority during the monitoring period. 'Controlled movement' involves reporting intended local, national, or international travel to the health authority to receive clearance for the intended travel (commercial travel is prohibited, although the use of local public transportation may be allowed).3
Initial Handling of an Ebola Suspect
Once you (and/or your local public health department) decide that a patient might constitute a potential Person Under Investigation (PUI), you must take immediate measures to protect your other patients, your staff, and yourself.
Isolate the Patient:
- IMMEDIATELY isolate the patient in a designated and predetermined room.
- Limit staff exposure (to the patient AND isolation room) to the fewest necessary, utilizing original Health Care Providers whenever possible to manage all aspects of patient care.
- Post infection-control trained personnel at patient's closed door, to ensure consistent and proper use of Personal Protective Equipment (PPE) by all persons entering the patient's isolation room.
- Maintain a log of all persons who enter and exit the patient's room, with evaluation of the proper PPE upon entry and a description of the condition of PPE upon exit4.Using a coded picture chart of possible PPE will reduce PPE recording times.
- Prevent entry of visitors into the patient's room - essential staff ONLY.3
- Provide a means of communications if the patient is a care provider for young children (or special needs individuals), in order to prevent panic.
- Use caution when approaching a potential Ebola patient, as they may exhibit delirious, erratic, or violent behavior, which could put staff at risk (e.g., flailing, staggering)1.
Protect Yourself and Your Staff:
- Utilize a buddy system when donning and doffing Personal Protective Equipment (PPE).
- PPE should include SINGLE-USE, DISPOSABLE:
- waterproof boot covers (covering to mid-calf)
- N95 respirator
- full-face shield
- surgical hood
- waterproof apron (covering full torso to mid-calf)
- double gloves (long-cuff, nitrile)
- Remove PPE with the greatest of care (as this is the most frequent occasion for self-contamination), utilizing the buddy system to prevent inadvertent exposure, while a separate Containment Monitor observes and documents any potential exposures.
- Health Care Providers should perform hand hygiene with Alcohol-Based Hand Rub before and throughout the doffing of PPE.
- PPE should be worn during environmental cleaning (utilizing initial HEALTH CARE PROVIDER to limit exposure risk to additional staff), following all guidelines outlined above.4
Conduct a Thorough Interview of the Patient:
- Create a timeline for onset of symptoms
- Create a detailed and precise travel history (dates, times, places)
- Create a thorough and comprehensive 'patient contact list' since the most probable date of symptom onset (remember, a low-grade fever might not have been recognized by the patient for a few days)5
If Immediate Life-Sustaining Procedures MUST* be Performed
* To avoid inadvertent exposure to clinic staff, make an attempt to minimize ANY invasive procedures (including blood-draws) that are not IMMEDIATELY necessary to stabilize the patient 1
The timely transfer of a patient to a designated Ebola-care hospital is preferable to treatment in an Urgent Care or Primary Care setting, due to the superior resources and decontamination protocols in the hospital setting. The CDC indicates the necessity of treatment of other medical conditions (like hypertension and diabetes), as well as the assessment of potential comorbidities/alternate diagnoses; however, the risk of exposure to Urgent and Primary Care staff is greater than at the hospital level, due to the superior sterility of the isolation rooms and lab facilities in the hospital setting (it is unclear if the CDC directive as of October 20, 2014 is directed towards hospitals in particular or towards all potential healthcare points of contact).5
IF, however, medical-stabilizing procedures MUST be performed, the following guidelines should be followed:
- Use infectious-disease-case-dedicated, preferably disposable, medical equipment
- Limit the use of needles and other sharps as much as possible and dispose of them in puncture-proof, sealed containers
- Laboratory testing should be limited to the bare minimum necessary6
- Limit use of Aerosol-Generating Procedures (AGP) to life-saving functions ONLY* (i.e., open suctioning of airways, endotracheal intubation, cardiopulmonary resuscitation)1, and utilize an N95 respirator and covering head gear
- Perform frequent gloved-hand disinfection utilizing an alcohol-based hand rub5
If a Health Care Provider (HCP) is Exposed
If PERCUTANEOUS or MUCOCUTANEOUS exposure to blood or body fluids occurs, HEALTH CARE PROVIDER should:
- Immediately stop working
- Immediately flush affected skin surfaces with soap and water and/or irrigate affected mucous membranes with copious amounts of water or eyewash solution6
- Immediately contact the Containment/PPE Monitor for an assessment5
- Report all exposures to local health department for post-exposure management
- Medical Evaluation
- Medical Testing (potentially)
- Fever & Symptom Monitoring/Reporting (2x daily)
- Work Exclusion (minimum 21 days)6
Due to the exposure issues at Dallas Presbyterian Hospital in early October, it now seems prudent for all Health Care Providers who interact with patients or patient samples to self-monitor for fever and other symptoms for 21 days after the last contact, so that in the event of occult exposure, infected Health Care Providers can receive the earliest diagnosis and treatment (which has proven vital to survival). At the first sign of symptoms, the HEALTH CARE PROVIDER should immediately self-isolate and alert the local health department for monitoring, evaluation, and potential testing.
Responsible Transfer of Patient to Receiving Facility
- Take transportation direction from the receiving hospital Emergency Department and/or your local or state health department
- Notify the receiving healthcare facility, so that proper precautions may be prepared in advance of receiving the patient
- Take note of logistical information from receiving facility, such as where to park (if patient is not to be transported by ambulance, also advise the patient not to mingle with other patients), which entrance to use, etc.1
- Inform the US Centers for Disease Control and Prevention (CDC), via the 770-488-7100 hotline, or via firstname.lastname@example.org
As part of preparation for potential Ebola threats, a short-list of public health reporting contact information is invaluable. I suggest you take the time to find your local contact information, and confirm that it is still OPERATIVE (before you have to use it). Make the information available to all personnel and drill on its use.
Local Health Department: _________________
State Health Department: _________________
Preferred Receiving Facility: _________________
CDC: email@example.com 770-488-7100
Note from TMA Here are some additional resources to keep handy:
- DSHS Infectious Disease Unit: (800) 252-8239
- DSHS Health Service Regions, Regional Medical Directors
It is my sincere hope that these plans may be of benefit to my fellow Urgent Care and Primary Care Physicians. I would like to emphasize that the information provided is up-to-date as of the writing of this article, but my expectations are that these suggestions will change often and quickly as the pandemic evolves. We should all strive to keep up with the newest protocol guidelines, as the CDC posts them.
I have chosen the side of caution in deciding which protocol suggestions to include (i.e., a lower fever temperature threshold, the 30-day exposure follow-up criteria over 21-days, the stringent end of exposure reporting), with the expectation that greater vigilance will save more lives.
Our Urgent and Primary Care facilities are in the unique position of being at the frontline to much of the infectious disease presentations in our local communities. Much of our time will necessarily be spent reassuring the "worried well." Let us stay well informed, highly prepared, and calmly vigilant, for the health of our patients and ourselves.
1. Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html. Updated October 21, 2014. Accessed October 21, 2014.
2. Case Definition for Ebola Virus Disease (EVD). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/case-definition.html. Updated September 5, 2014. Accessed October 21, 2014.
3. Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html. Updated August 29, 2014. Accessed October 21, 2014.
4. Guidance on Personal Protective Equipment to be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Updated October 21, 2014. Accessed October 21, 2014.
5. When Caring for Suspect or Confirmed Patients with Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/caring-for-ebola-suspects.html. Updated October 20, 2014. Accessed October 21, 2014.
6. Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated October 20, 2014. Accessed October 21, 2014.
Checklist for Patients Being Evaluated for Ebola Virus Disease (EVD) in the United States. Centers for Disease Control and Prevention Web site. www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf. Accessed October 21, 2014.
Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html. Updated October 21, 2014. Accessed October 21, 2014.
What You Need to Know about Ebola. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/what-need-to-know-ebola.pdf. Updated October 16, 2014. Accessed October 22, 2014.
Health Care Workers: Could it be Ebola? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/could-it-be-ebola.pdf. Accessed October 22, 2014.
Infographic: Facts about Ebola in the U.S. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/vhf/ebola/pdf/infographic.pdf. Accessed October 22, 2014.
American Academy of Urgent Care Medicine (Rogers, Weitzman); Booz Allen Hamilton (Buzard); DDC Corp (Weitzman)
Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. (firstname.lastname@example.org)
Drafting of the Manuscript: Rogers, Boyd-Rogers
Critical revision of the manuscript: Weitzman, Buzard
Affiliations:1American Academy of Urgent Care Medicine; 2Booz Allen Hamilton; 3DDC Corp.
Address correspondence to: Brian B. Rogers, DO, MPH, Board of Directors, American Academy of Urgent Care Medicine. [email@example.com]
Short Title: Ebola Protocols in Urgent and Primary Care Settings
Abbreviations: CDC - U.S. Centers for Disease Control and Prevention; PPE - Personal Protective Equipment
Funding Source: No funding was secured for this study.
Financial Disclosure: The remaining authors have no financial relationships relevant to this article to disclose.
Conflict of Interest: The authors have no conflict of interest to disclose.
Brian B. Rogers and Alexandra Boyd-Rogers: Dr. Rogers and Ms. Boyd-Rogers drafted the initial manuscript and approved the final manuscript as submitted.
David M. Weitzman and Gregory S. Buzard: Drs. Weitzman and Buzard reviewed and revised the manuscript, and approved the final manuscript as submitted.