Critical Success Factors

Compliance is mandatory, but how compliance is achieved is crucial for healthcare organizations. A payer or provider whose strategy is to do the bare minimum (as many did with the Privacy and Security Rules) will be wasting a great opportunity to implement positive change and putting its business continuity at risk.

How compliance is achieved will not only determine the ability to bill and collect, but whether or not it will improve financial and operational performance by taking advantage of the power of ICD-10. The following are actions, based upon experience with all types of healthcare organizations, which lead to successful implementation:

Read the Rules: In addition to seeking advice from consultants, download and read the rules! Just as with the implementation of HIPAA Privacy and Security Rules, there is a tremendous amount of misinformation and misunderstanding about administrative simplification and the Electronic Transactions and Code Sets Rule.

Achieving compliance is understanding that this is all about Change Leadership/Business Process Reengineering: ICD-10 affects virtually every clinician, staff member, and job function within payer and provider organizations. Not gaining their understanding and buy-in could result in a poor implementation and poor financial performance.

Start NOW: Based upon ICD-10 implementations in other countries (the US is the only industrialized country not using ICD-10), a typical healthcare organization required three to four years for implementation. Retrospectively, those healthcare organizations invariably wished they had started sooner and had more time.

Don't wait for ICD-11: ICD-11 has not been developed. The international version will not be ready until approximately 2015 and will not be implemented until approximately 2020. Based on the development of ICD-10-CM and ICD-10-PCS for use in the US, the US version will not be ready for several years after the development of the international version.

Face ICD-10 head on, because there is no workaround: There are interim strategies and tactics being discussed and developed to accomplish what should be considered short-term workarounds. These should be viewed as interim backup plans at best. For the long-term, payers and providers will only achieve the total benefit of ICD-10 through full implementation.

Perform a gap analysis to evaluate all systems and processes: By conducting a gap analysis, healthcare organizations develop a roadmap to make decisions regarding remediating, upgrading, replacing, or outsourcing systems and processes. The cost of remediating legacy systems may be prohibitive for some healthcare organizations. Replacement of non-compliant systems could be a key to the strategy of on-going HIPAA compliance and business continuity: fix it once to reduce the cost and complexity of compliance with current and future HIPAA Rules.

Interoperability and integration are absolutely required: To reduce implementation time, number of interfaces, risk, and total cost of ownership (TCO), the strategy for healthcare organizations should be focused on selecting systems that provide interoperability and complete integration.

Perform vendor due diligence: Healthcare organizations must ensure that their software vendors will have ICD-10-compliant releases and mandate ample time for testing and training. As with the Privacy and Security Rules, there will be small, under-capitalized vendors that will not be compliant. Organizations should make this determination as soon as possible and, if necessary, prepare to select a new vendor.

Evaluate EMR options: As a practical matter, providers will eventually not be able to function without an EMR. Use of an EMR is particularly important for hospitals to obtain the full benefits of automated clinical documentation. The adoption of an EMR is a drastic operational change, especially for physicians. Providers must allow time to fully train on the use of an EMR. It can take from three to nine months for clinicians to adapt and recover from the loss of productivity that normally accompanies an EMR implementation. If the EMR is not carefully selected and properly implemented, lost physician productivity (typically 25 to 40 percent) may never be recovered.

Get the right tools: Talk with software vendors to learn who they are partnered with to implement coding and auto-coding. With the complexity and number of codes, manual coding is not realistic in most cases.

Don't skimp on training: Training is consistently cited as a top critical success factor. The number of staff members needing training is normally underestimated. The level of training will vary, but it is needed throughout the entire healthcare organization.